Investigators Suggest Better Predictors to Diagnosing Mental Illness

Claire Gillan, PhD

Claire Gillan, PhD

In a new study, investigators suggest a need for more individualized approaches to defining mental illnesses because of substantial overlap across different disorders.

A team of investigators, led by Claire M. Gillan, PhD, School of Psychology, Trinity College Institute of Neuroscience and Global Brain Health Institute, recently completed a 285-patient cross-sectional study in the US for individuals diagnosed with obsessive-compulsive disorder (OCD) and/or generalized anxiety disorder (GAD).

The investigators found self-reported compulsivity was more strongly linked with goal-directed deficits than a diagnosis of OCD compared with GAD.

The results could have implications for research assessing the association between brain mechanisms and clinical manifestations, as well as for understanding the structure of mental illness.

The aim of the study was to identify if deficits in goal-directed planning better identified by self-reported compulsivity or a diagnosis of obsessive-compulsive disorder. Each patient completed a telephone-based diagnostic interview by a trained rater, internet-based cognitive testing, and self-reported clinical assessments between 2015-2017.

The investigators collected follow-up data as well to test for replicability.

Performance was measured on a test of goal-directed planning and cognitive flexibility using the Wisconsin Card Sorting Test (WCST), as well as a test for abstract reasoning.

Clinical variables included a DSM-5 diagnosis of OCD and GAD, as well as 3 psychiatric symptom dimensions—general distress, compulsivity, and obsessionality—derived from a factor analysis.

Overall, deficits in goal-directed planning in OCD was strongly tied with a compulsivity dimension than with a OCD diagnosis.

The mean age of the 285 patients was 32, with a range of 18-77 years old. The patient population included 219 females, 111 individuals with OCD, 82 patients with GAD, and 92 patients with both disorders.

“A diagnosis of OCD was not associated with goal-directed performance compared with GAD at baseline (P = .18),” the authors wrote. “In contrast, a compulsivity dimension was negatively associated with goal-directed performance (P = .003).”

This pattern was also found with abstract reasoning tasks as well as WCST.

“The compulsivity dimension was associated with abstract reasoning (P  .001) and several indicators of WCST performance (P  .001), whereas OCD diagnosis was not (abstract reasoning: P = .56; categories completed: P = .38),” the authors wrote.

However, other symptom dimensions related to OCD, obsessionality, and general distress had no reliable association with goal-directed performance, WCST, or abstract reasoning.

Obsessionality also had a positive association with requiring more trials to reach the first category on the WCST at baseline (P = .04), while general distress was linked to impaired goal-directed performance at baseline (P = .01).

Despite this, neither survived correction for multiple comparisons or was replicated at follow-up testing.
 
In the past, dimensional definitions of transdiagnostic mental health problems has been recommended as an alternative to a categorical diagnosis. Using this technique allows clinicians to capture heterogeneity within diagnostic categories and similarity across them to bridge more naturally psychological and neural substrates.

“This study suggests that transdiagnostic compulsivity symptoms may have greater biological validity than a diagnosis of obsessive-compulsive disorder,” the authors wrote.

There are fundamental issues with using popular international categories for neurobiological research such as the DSM-5 and International Classification of Mental and Behavioural Disorders, 10th Revision.

While diagnostic groups are highly heterogeneous, patients often have the same diagnosis with vastly different symptom profiles.

Individuals without a psychiatric diagnosis usually differ from patients with a diagnosis in several ways beyond the diagnosis under investigation, including anxiety, depression, physical illness, and early-life adversity.

As a result, potential biomarkers, intermediate phenotypes, and etiologic substrates often can only show a modest association with a categorical clinical phenotype, but is unlikely to be specific to that phenotype.

The study, “Comparison of the Association Between Goal-Directed Planning and Self-reported Compulsivity vs Obsessive-Compulsive Disorder Diagnosis,” was published online in JAMA Psychiatry.

What Is Trypophobia?

If you’ve ever experienced strong aversion, fear or disgust while looking at objects or photos of objects with lots of little holes, you might have a condition called trypophobia. This strange word describes a type of phobia in which people have a fear of, and therefore avoid, patterns or clusters of small holes or bumps, says Ashwini Nadkarni, M.D., a Boston-based associate psychiatrist and instructor at Harvard Medical School.

While the medical community does have some uncertainty about the official classification of trypophobia and what causes it, there’s no doubt that it manifests in very real ways for individuals who experience it.

So, What Is Trypophobia?

There’s little known about this condition and its causes. A simple Google search of the term will bring up loads of potentially triggering trypophobia pictures, and there are even online support groups for trypophobics to warn each other of things like movies and websites to avoid. Yet, psychologists remain skeptical of what, exactly, trypophobia is and why some people have such adverse reactions to specific images.

“In my 40-plus years in the field of anxiety disorders, no one has ever come in for treatment of such a problem,” says Dianne Chambless, Ph.D., a psychology professor at the University of Pennsylvania in Philadelphia.

While, Martin Antony, Ph.D., a professor of psychology at Ryerson University in Toronto and author of The Anti-Anxiety Workbook, says he did get an email once from someone who was struggling with trypophobia, he has never personally seen anyone for the condition.

Dr. Nadkarni, on the other hand, says she treats a fair number of patients in her practice who present with trypophobia. Although it’s not named in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), an official manual compiled by the American Psychiatric Association used as a means for practitioners to assess and diagnose mental disorders, it is recognized under the umbrella of specific phobias, says Dr. Nadkarni.

Why Trypophobia Isn’t Officially Considered a Phobia

There are three official diagnoses for phobias: agoraphobia, social phobia (also referred to as social anxiety) and specific phobia, says Stephanie Woodrow, a Maryland-based licensed clinical professional counselor and nationally certified counselor specializing in the treatment of adults with anxiety, obsessive-compulsive disorder, and related conditions. Each of these is in the DSM-5. Basically, the specific phobias category is the catch-all for every phobia from animals from needles to heights, says Woodrow.

It’s important to note that phobias are about fear or anxiety, and not disgust, says Woodrow; however, obsessive-compulsive disorder, which is a close friend to anxiety disorder, can include disgust.

Trypophobia, on the other hand, is a bit more convoluted. There is a question of whether it might be better classified as a generalized fear or disgust toward dangerous things, or whether it can be considered an extension of other disorders such as a generalized anxiety disorder, says Dr. Nadkarni.

She adds that existing studies on trypophobia indicate that it does involve some sort of visual discomfort, particularly toward imagery with a certain spatial frequency.

If trypophobia conclusively fell under the classification of a phobia, then the diagnostic criteria would include an excessive and persistent fear of the trigger; a fear response out of proportion to the actual danger; avoidance or extreme distress related to the trigger; a significant impact on the person’s personal, social or occupational life; and at least six months of duration in symptoms, she adds.

Trypophobia Pictures

Triggers are often biological clusters, such as lotus-seed pods or wasps’ nests that occur naturally, though they can be other types of non-organic items. For example, the Washington Post reported the three camera holes on Apple’s new iPhone were triggering for some, and the new Mac Pro computer processor tower (dubbed the “cheese grater” among the tech community) sparked conversation around trypophobia triggers on some Reddit communities.

A few studies have linked the emotional response of trypophobia to the triggering visual stimuli as part of an aversion response rather than a fear response, says Dr. Nadkarni. “If disgust or aversion is the primary physiological response, this may suggest the disorder is less of a phobia since phobias trigger the fear response, or ‘fight or flight’,” she says.

What It’s Like to Live with Trypophobia

Regardless of where science stands, for people like Krista Wignall, trypophobia is a very real thing. It only takes a glimpse of a honeycomb—in real life or on a screen—to send her into a tailspin. The 36-year-old Minnesota-based publicist is a self-diagnosed trypophobic with a fear of multiple, small holes. She says her symptoms began in her 20s when she noticed a strong aversion to items (or photos of items) with holes. But more physical symptoms began to manifest as she entered her 30s, she explains.

“I would see certain things, and it felt like my skin was crawling,” she recalls. “I would get nervous ticks, like my shoulders would shrug or my head would turn—that body-convulsion type of feeling.” (Related: Why You Should Stop Saying You Have Anxiety If You Really Don’t)

Wignall dealt with her symptoms the best she could with little understanding of what was causing them. Then, one day, she read an article that mentioned trypophobia, and although she had never heard the word before, she says she immediately knew this is what she had been experiencing.

It’s a little hard for her to even talk about the incidents, as sometimes just describing things that have triggered her can make the convulsions come back. The reaction is nearly instantaneous, she says.

While Wignall says she wouldn’t call her trypophobia “debilitating”, there’s no doubt it’s impacted her life. For example, her phobia forced her to get out of the water two different times when she spotted a brain coral while snorkeling on vacation. She also admits to feeling alone in her phobia because everyone she opens up to about brushes it off, saying they’ve never heard of it before. However, there now seem to be more people speaking out about their experience with trypophobia and connecting with others who have it via social media.

Another trypophobia sufferer, 35-year-old Mink Anthea Perez from Boulder Creek, California says she was first triggered while dining at a Mexican restaurant with a friend. “When we sat down to eat, I noticed her burrito had been cut down the side,” she explains. “I noticed her whole beans were in a cluster with perfect little holes between them. I was so grossed out and horrified, I started itching my scalp really hard and just freaked out.”

Perez says she’s had other frightening occurrences, too. The sight of three holes in a wall at a hotel pool sent her into a cold sweat, and she froze on the spot. Another time, a triggering image on Facebook led her to break her phone, throwing it across the room when she couldn’t stand to look at the image. Even Perez’s husband didn’t understand the seriousness of her trypophobia until he witnessed an episode, she says. A doctor prescribed Xanax to help ease her symptoms—she can sometimes scratch herself to the point she brakes the skin.

Trypophobia Treatments

Antony says exposure-based treatments used to treat other phobias that are done in a controlled way, where the sufferer is in charge and not forced into anything, may help people learn to overcome their symptoms. For example, gradual exposure to spiders can help ease fear for arachnophobes.

Dr. Nadkarni echoes the sentiment that cognitive-behavioral therapy, involving consistent exposure to the feared stimuli, is an essential component of treatment to phobias because it desensitizes people to their feared stimuli. So in the case of trypophobia, treatment would involve exposure to small holes or clusters of these holes, she says. Yet, since the blurred line between fear and disgust is present in people with trypophobia, this treatment plan is just a cautious suggestion.

For some trypophobia sufferers, getting over a trigger may just require looking away from the offending image, or focusing their attention on other things. For others like Perez, who are more deeply affected by trypophobia, treatment with anxiety medication may be needed to better control symptoms.

If you know someone who’s trypophobic, it’s key to not judge how they react or how triggering images make them feel. Often, it’s beyond their control. “I’m not afraid [of holes]; I know what they are,” says Wignall. “It’s just a mental reaction that goes into a body reaction.”

For patients with eating disorders, cannabis may be the right medicine | Grow

This article was republished from Weedmaps News under a syndication agreement. Read the original article here.

It’s morning in New York City, and Jessica Mellow is preparing for a long day. She pours her first of many cups of coffee and steels herself for another day of work — and another day of anorexia treatment. Not only does the body-paint model have a long session booked, she also has an appointment with her psychiatrist, and dinner with a meal-support specialist. She takes some cannabidiol (CBD) oil to help calm her nerves. Her anxiety is ever-present.

“I’ve found that when I use a bit of pot or take some CBD oil, it helps with anxiety and pain, and helps me get to sleep, sans side effects,” Mellow said. “Treatment for anorexia is trickier than for a lot of mental illnesses, largely because it requires doing the exact opposite of what feels safe and instinctual. If the brain perceives food as a threat, but the only way to get better is to continuously eat, the anxiety increases drastically, and as treatment goes on, often gets worse instead of better.”

Anorexia isn’t a qualifying condition for a medical marijuana certification in New York, even though a review of studies has shown cannabinoids can decrease anxiety and promote weight gain in anorexic patients.

Mellow, for one, is eager for more anorexia treatment protocols. “I think it would be really helpful to have [legal] cannabis as an option,” she said.

Eating Disorders’ Origins

Despite what TV movies depict, eating disorders don’t just stem from a drive to be thin. Some people are born with a genetic predisposition to anorexia, bulimia, and binge-eating disorder. Further, the intrusive thoughts that often plague sufferers are similar to those of obsessive-compulsive disorder (OCD).

According to the National Eating Disorders Association (NEDA), “two-thirds of those with anorexia [show] signs of an anxiety disorder (including generalized anxiety, social phobia, and obsessive-compulsive disorder) before the onset of their eating disorder.” These comorbid conditions are only part of the reason anorexia is notoriously hard to treat.

Restrictive eating disorders such as anorexia and avoidant/restrictive food intake disorder (ARFID) can lead to progressive starvation that affects the brain, and therefore the intellect, making treatment for these patients even more challenging. Critically ill anorexic patients may want to eat, and want to recover, but may feel trapped in ritualistic thoughts and behaviours.

Bulimia and binge-eating disorder present a different but similar set of challenges, and symptoms of these disorders often overlap with anorexia symptoms. Binges can last for hours and result in the consumption of tens of thousands of calories. People with bulimia or binge-eating disorder can be of a normal weight or very overweight. Bodyweight doesn’t change the severity of the disease, but due to the risk of starvation or heart failure, anorexia remains the deadliest of all psychiatric disorders, with an estimated mortality rate of 10%. 

Eating disorders and the endocannabinoid system

The endocannabinoid system (ECS) is a network of receptors, enzymes, and endocannabinoid molecules that maintains homeostasis, or a range of healthy functions in the body. The CB1 receptors, found in the central nervous system, transmit a “calm down” signal to overactive neurons. Because these receptors are plentiful in brain regions that control food intake, clinical evidence suggests that there may be a link between a defective ECS and the development of an eating disorder.

The ECS is involved in the regulation of eating and energy balance, and CB1 receptors — one of the two kinds of cannabinoid receptors in our brains, the other being the CB2 receptors — are plentiful in the brain regions that regulate hunger and control eating behaviours. Because of the way they bind to CB1 receptors, ingested cannabinoids can help reduce patients’ anxiety and increase (or decrease, in the case of high-CBD strains) the amount of food they consume. What stoners have long known to be true turns out to be backed by science: Cannabis can chill you out and give you the munchies.

“Cannabis helps me in two ways. First, it helps with hunger cues,” Cassidy said. “When you’ve been restricting for a while, your body stops asking for food when it needs to. The munchies help with that. Second, [cannabis] helps with the anxiety. It kind of quiets the wave of negative self-talk that often comes with eating.”

Anorexia sufferer Cassidy, whose name has been changed agrees. “Cannabis helps me in two ways. First, it helps with hunger cues,” Cassidy said. “When you’ve been restricting for a while, your body stops asking for food when it needs to. The munchies help with that. Second, [cannabis] helps with the anxiety. It kind of quiets the wave of negative self-talk that often comes with eating.”

The OCD connection 

The American Psychiatric Association’s “Practice Guideline for the Treatment of Patients with Eating Disorders” states that eating disorders are often comorbid with other psychiatric conditions, particularly OCD, anxiety disorders, and personality disorders. And according to the International OCD Foundation, 64% of people with eating disorders also have an anxiety disorder, and 41% of those have OCD.

What all these statistics mean is that people with eating disorders — especially the restrictive type — often operate according to a strict set of rules that may not make sense to people without eating disorders. For example, a person with anorexia may deem foods “safe” and “unsafe” based on reasons other than calories or nutrient content, or develop rituals around how they cut food and where they place it on the plate. It’s not so different from having to turn the lights on and off a certain number of times before leaving the house, or having to wash one’s hands a certain number of times before going to bed, behaviours typically associated with OCD.

In a 2019 study published in Cannabis and Cannabinoid Research, researchers from the New York State Psychiatric Institute at the Columbia University Department of Psychiatry found preliminary evidence that suggests the body’s endocannabinoid system may play a role in OCD, and cited case reports from three patients for whom the cannabinoid drug dronabinol reduced compulsive behaviours. One patient, who displayed treatment-resistant OCD symptoms following a thalamic stroke, was able to participate in cognitive behavioural therapy (CBT) after using dronabinol. While more research is needed, this preliminary evidence suggests that cannabis-based treatments may allow patients struggling with compulsive behaviours to more effectively participate in talk therapy. In addition, a 2005 study showed that rates of the endocannabinoid anandamide are increased in patients with anorexia and binge-eating disorder, but not in patients with bulimia. The possibility of modulating the endocannabinoid system to treat certain eating disorders deserves more research.

Future of eating disorder treatment

Scientific studies of patients with HIV and cancer show that cannabis increases appetite and can lead to significant, life-saving weight gain. However, established eating-disorders treatment programs have been slow to accept the medical efficacy of cannabis.

Fortunately, clinicians such as Dr. Ziv Cohen, a psychiatrist in New York City licensed to certify patients to the state medical-marijuana program, think it could be a helpful addition to eating disorder treatment protocols.

“I think that there is a lot of promise in cannabis-based products for restrictive eating disorders in the same way that cannabis products are very helpful for cancer patients who have problems with their nutrition,” Cohen said. “Anxiety is reduced and appetite is increased, and that combination can kind of push patients over the hump and get them to eat things that they wouldn’t normally eat, or that they’re phobic about.”

Cohen stressed that not all patients with eating disorders are good candidates for cannabis medicine; comorbidity is an important consideration. Inducing uncontrollable munchies in patients who purge has obvious consequences, but for patients with trauma histories who restrict or binge in response to post-traumatic stress disorder (PTSD) triggers, Cohen said cannabis could be helpful.

“We want to make sure we’re not conditioning the patient to only be able to eat when they’re using a cannabis product; just like with other medications, we would want [cannabis] to facilitate developing regular eating habits, not to become a ritual that is necessary [in order] to eat,” Cohen said. “Cannabis treatment could be very helpful, as long as it’s within the context of a good multidisciplinary team.”

Mellow agreed, and stressed the importance of her treatment team and the need for alternatives to psychiatric medications.

“Malnutrition can prevent psychiatric medications from being effective, so having [cannabis] to help with the anxiety could potentially make a treatment that often feels punitive much more tolerable and effective,” Mellow said.

“I don’t believe there’s any miracle cure,” Mellow said, “but if cannabis can reduce some of the biggest barriers to treatment — exhaustion, anxiety, physical discomfort — that leaves more room to focus directly on recovery, and I don’t see how that could be anything but positive.”

Brain immune cells may protect against OCD, anxiety

Over the last decade, scientists have been discovering that microglia, a type of immune cell that resides in the brain, do more than respond to illness and infection.

New research suggests a novel treatment for OCD and anxiety.

Now, new research in mice has linked the dysfunction of microglia of a particular genetic lineage to anxiety and obsessive-compulsive disorder (OCD).

The recent Cell Reports study also shows that female sex hormones can worsen the anxiety symptoms that arise when this subset of microglia do not function correctly.

The discovery sheds light on the brain biology of anxiety and conditions that relate to it, such as OCD, whose root causes have remained unclear.

“More women than men experience debilitating anxiety at some point in their lives,” says lead study author Dimitri Traenkner, Ph.D., a research assistant professor in biological sciences at the University of Utah in Salt Lake City.

“In this study,” Traenkner adds, “[we] were able to link anxiety to a dysfunction in a type of microglia and to female sex hormones.”

Microglia have many functions

Since their discovery in the 1920s, scientists have come to appreciate the important roles that microglia play in the brain following injury, infection, and illness.

They have shown that these innate immune cells play a part in conditions ranging from Alzheimer’s disease and multiple sclerosis to brain cancer.

More recently, however, a wealth of research has revealed that microglia have a large repertoire of functions.

Studies have shown, for instance, that microglia contribute to many aspects of brain development, including the generation of the myelin sheath that protects nerve fibers and the stimulation and pruning of connections between brain cells.

In addition, scientists are starting to appreciate that the influence of microglia extends into behavior.

‘At least two different lineages’

In their study paper, Traenkner and colleagues cite studies that have suggested that under conditions of prolonged stress, abnormal microglia activity may cause depression or anxiety.

They also explain that not all microglia are the same. For example, in their own research, they “recently demonstrated that there are at least two different lineages of microglia” and that it is possible to program them to do different things.

In that earlier work, the team identified a specific subset of microglia whose precursors express the protein Hoxb8 during embryonic development.

Hoxb8 is a transcription factor, which is a protein that can alter cell behavior by switching genes on and off.

It appears that about one-third of all microglia in the adult mouse brain descend from Hoxb8 precursors.

Other researchers have also shown that mice that have no Hoxb8 tend to overgroom, a behavior similar to the human disorder trichotillomania, a type of OCD that causes individuals to pull out their hair. However, they did not establish which cells are involved.

Hoxb8-lineage microglia

What Traenkner and colleagues did in the new study was to identify the cells responsible for this behavior as microglia that have descended from precursors with a Hoxb8 lineage.

Their experiments showed that inactivating Hoxb8-lineage microglia in mice caused overgrooming and that active Hoxb8-lineage microglia can stop the compulsive behavior.

“Researchers have long suspected,” notes Traenkner, “that microglia have a role in anxiety and neuropsychological disorders in humans because this cell type can release substances that may harm neurons.”

So, the fact that microglia can protect against anxiety surprised them, he adds.

In their experiments, the researchers also saw how female sex hormones can worsen the OCD and anxiety that arises from dysfunctional Hoxb8-lineage microglia. The symptoms were consistently more severe in the female mice than in the male mice.

In addition, female mice displayed anxiety that was not present in the males. The team saw evidence of this in a new test that they developed and validated, in which the animals’ pupils dilated markedly under stress conditions.

To confirm that female sex hormones were driving the symptoms of OCD and anxiety, the researchers varied the animals’ levels of two female sex hormones: estrogen and progesterone.

When the team manipulated these hormone levels in the female mice to resemble those typically present in males, the OCD and anxiety symptoms in the female mice were like those of males.

Conversely, when the hormones in males were at the levels typically present in females, the OCD and anxiety symptoms in the male mice were like those of females.

New direction for drug research

Traenkner suggests that these findings make a strong case for the existence of a mechanism that links biological sex and genetic family history in the risk of developing anxiety-related disorders.

The team does not claim to have found a cure for anxiety but suggests that the findings point to a new direction in which to look for new drugs to treat the condition.

Nearly one-third of adults in the United States will experience an anxiety disorder at some point in their lives, according to estimates from the National Institute of Mental Health, which is one of the National Institutes of Health (NIH).

The symptoms of anxiety can be so severe that they disrupt people’s relationships and their ability to work, study, and carry out their daily activities.

[This study] opens up a new avenue for thinking about anxiety. Since we have this model, we have a way to test new drugs to help these mice, and hopefully, at some point, this will help people.”

Dimitri Traenkner, Ph.D.

Obsessive-Compulsive Disorder and Secrecy

A critically important clinical feature of obsessive-compulsive disorder (OCD) is the pervasive secrecy of patients suffering from the condition. OCD involves recurrent, disturbing thoughts and recurrent and excessive behaviors, including rituals and constant checking. Secrecy about OCD symptoms has been responsible for a long-standing, marked underestimation of the true incidence of the illness. Although clinical recognition has increased, patients’ secrecy, shame and denial continue to have an impact on assessment, treatment, and the validity of research results.

More than with many other psychiatric disorders, OCD patients do not spontaneously or voluntarily report their symptoms to health providers or even intimate family members. OCD patients fear that revealing their symptoms will lead to severe censure and disapproval because the symptoms are often ego-dystonic and seemingly antisocial or bizarre in nature: repetitive obscene or blasphemous phrases, for example, or thoughts of attacking children or loved ones or removing one’s clothes in public. Also, there is reason to believe that secrecy has its own function in both the formation and perpetuation of OCD symptoms, which serve to protect against painful anxiety.

The feelings of shame and desire for secrecy strongly influence patients’ open acknowledgment of the senselessness of symptoms. OCD patients are characteristically highly concerned with approval from other people, and their acknowledgment or denial of symptom senselessness is often determined by assumptions about the expectations of interviewers, raters or administrators of self-report measures, rather than provisions of truthful accounts. There is very likely somewhat more acknowledgment of senselessness in those indulging in checking or else cleanliness behaviors, the latter being more congruent with the values of middle-class culture and therefore more individually and socially acceptable.

Attempts at diagnostic measurement, including studies of accompanying personality disorder symptoms, have been extensively confounded by the problem of shame and secrecy. These studies have shown markedly variable results. Such wide variation in itself suggests unreliability of diagnostic instruments, but less shameful-feeling obsessive-compulsive personality disorder (OCPD) patients are also secretive about reporting certain behaviors and characteristics—in this case, irrational control, hoarding, rigidity, miserliness, and meticulous perfectionism.

Sensitive extended clinical evaluations, because of trust and familiarity developed, reveal a full range of OCD patterns. Patients will readily supply answers when asked simple questions in an unthreatening manner. The questions must rely on voluntary report and in each case, the patient should be asked to evaluate the excessiveness and inappropriateness of behaviors stipulated.

How much is “excessive”? It is up to the trained clinician together with the patient to determine the answer. This orientation is also necessary for ongoing treatment and the following of specific features of the illness. In order to determine whether the patient engages in excessive checking behavior, information is gathered about job histories, including whether one repeats tasks. If so, how often?

At home, how many times is the lock on the door tested when the patient goes out, how often are the stove burners checked, how long does it take to dress in the morning? In order to assess cleanliness, the patient is asked about patterns of housekeeping, showering and handwashing. Are particular places avoided because of possible contamination or dirt? For symmetry and order, questions are directed toward preferred placement of objects in the home, pictures on the wall, and preferences about physical work environments.

For assessment of obsessional thinking, information is effectively evoked by identifying everyday difficulties in living and performing. Commonly reported problems in sleeping are followed by questions about the possibility of bothersome or repetitive thoughts that keep the patient awake. Similarly, if a patient reports distractions and inability to concentrate at work or at school, questions are asked about mental preoccupations.

Obsessive-compulsive disorder has long been hidden and difficult for both sufferers and therapists. Currently, various treatments are available with varying degrees of promise. A number of SSRI medications have shown beneficial effects, including clomipramine, fluoxetine, paroxetine, sertraline, and fluvoxamine—and psychotherapy is an absolute must.

A specialized brain cell could be a root cause of OCD and anxiety, especially in women

Anxiety disorders affect more than 40 million adults in the United States, making them the most common mental illness in the country.

Women, in particular, are at greater risk for anxiety and associated conditions such as Obsessive Compulsive Disorder.

The underlying causes of these disorders are still not very well understood, but new research suggests a specific type of brain cell may be responsible for certain behaviors common, Medical Xpress reported.

Scientists from the University of Utah have identified a potentially linked type of cell that plays a critical role during development in the womb. Lower levels of this cell type may play a role in the eventual onset of anxiety disorders.

The researchers looked specifically at a subset of microglia, a cell that helps wire together brain structures and neural circuitry. This subset, called Hoxb8-lineage microglia, accounts for about 30% of all microglia in the brain.

In a series of tests on mice, it was found that those who had Hoxb8-lineage microglia disabled showed excessive grooming behavior. The authors noted the similarity to trichotillomania, a condition that causes people to compulsively pull out their hair.

The findings were not only more noticeable in female mice, but ebbed and flowed when scientists adjusted the female sex hormones in both the female and male mice.

Curiously, the results of the study were not necessarily what the research team expected.

“Researchers have long suspected that microglia have a role in anxiety and neuropsychological disorders in humans because this cell type can release substances that may harm neurons,” lead author Dimitri Traenkner said. “So, we were surprised to find that microglia actually protect from anxiety, they don’t cause it.”

The study published in Cell Reports may form the basis of a new approach to developing drugs for those with anxiety disorders.

If You’re An Obsessive Compulsive Thinker, You May Notice These Thought Patterns

Have you ever felt painfully stuck on a thought loop in your head? While it’s common to go through periods where you think about a particular issue, scenario, thing, or person a whole lot — there is a difference between fixating on something and having obsessive compulsive thinking that truly intrudes on your life and peace of mind. If the latter sounds familiar, know that you aren’t alone, and there are both ways to tell if OCD is an issue for you, and the things you can do to cope with the symptoms.

As Tamar Chansky, Ph.D., founder of the Children’s and Adult Center for OCD and Anxiety and author of Freeing Your Child From Obsessive Compulsive Disorder, tells Bustle, OCD is a disorder where you have intrusive thoughts that are “unwanted, time-consuming, and can cause distress.”

“In other words they barge into your thinking when you don’t want them to,” Chansky says. “It’s different from being upset about something about your life and you feel stuck in a loop thinking about it.”

That is unpleasant too, Chansky says, but with OCD, often the content is not really relevant to your life. It may feel strange. You might be thinking about harm, contamination, being a bad person, or the evenness of items around you.

“The other part of OCD is that people do ‘compulsions’ or rituals to neutralize a thought,” Chansky says. “OCD makes an obstacle course for its sufferers, making them feel like they need to repeat, redo and rethink things that are not needing to be on their worry list at all,” Chansky says.

OCD can cause extreme stress and mental discomfort on the day to day. Shutterstock

“The core issue in OCD is unwillingness to accept certain kinds of uncertainty,” counselor Stephanie Woodrow, LCPC, NCC, who was recently named an emerging leader by the Anxiety and Depression Association of America, tells Bustle.

Obsessions are recurrent, persistent, unwanted, and intrusive thoughts or images that are disturbing and cause marked anxiety or distress, Woodrow says. The compulsions or rituals that accompany them for people with OCD are mental behaviors aimed at reducing distress, anxiety, disgust, or a “just not right” feeling.

“Research shows that everyone has unwanted, intrusive thoughts and images,” Woodrow says. “The difference between someone who develops OCD and someone who can dismiss them is the ability to not give those thoughts and images importance or value.”

Some of the common OCD themes include things like contamination with germs or bodily fluids, perfectionism, unwanted sexual thoughts, fear of illness, or superstition. And some of the common compulsions or rituals are things like checking and reviewing, seeking reassurance or confessing, thinking a safe thought, or ordering and arranging things, among many others.

Woodrow says that while research suggests a person must have a biological vulnerability in order to develop OCD, at this point researches don’t know what causes the “OCD gene” to kick in. But she does reiterate that “people do not cause their OCD, and neither does parenting.”

Woodrow says that options for treatment are extensive — they can include medications, outpatient, inpatient, or partial hospitalization therapy programs, mindfulness practice, and a variety of therapeutic modalities like Cognitive Behavioral Therapy (CBT).

Elise Hall, LCSW a clinical social worker with a private practice specializing in the treatment of OCD and anxiety disorders tells Bustle that “the gold standard” for OCD treatment is Exposure Response Prevention, wherein a trained therapist guides you through different exposure tasks to help your brain and central nervous system learn that the feared outcomes of the obsessive thoughts are unlikely and/or tolerable.

Chansky says too that professional help is definitely the way to go when you suffer from OCD. But on the day to day, a first step is to relabel the thought you are having as not being about you, and not being your fault.

“It’s a brain hiccup that is said in words, but still as meaningless as a hiccup,” Chansky says. “You need to train yourself to ‘under-react’ to the frightening thoughts because they only carry the weight you give them, they have no authority in your life unless you give them that attention.”

Of course, that doesn’t mean that recognizing that the thoughts are obsessive will make them disappear. It can be a long process, Chansky says. But one of the treatments for OCD is to essentially start skipping or “breaking the rules” of what your OCD brain is telling you what to do.

“Over time, as you stop tapping, touching, redoing, washing etc., via neuroplasticity, your brain re-learns that those warnings are unnecessary and starts filtering them out,” Chansky says. “Don’t avoid the OCD situations — face them, and change the rules gradually shaping your actions to how you would want to respond if you didn’t have OCD.”

Chansky says that if you’re even struggling with non-OCD thoughts getting stuck on a loop, it’s good to use neuroplasticity there too.

“Rather than jumping into worry mode whenever a thought comes in your mind, compartmentalize, create structure, and worry on a schedule rather than having those thoughts interfere in your work day,” Chansky says. “If you can’t kick the worry habit entirely, set a time for worrying 5 minutes where you name your fears and then fact check them.”

We have to shift out of worry mode intentionally to see that it is not useful to us, Chansky says.

If you’re concerned that OCD might be an issue for you, reach out for professional help. It is a treatable disorder — and you can find relief.

Experts:

Tamar Chansky, Ph.D., founder of the Children’s and Adult Center for OCD and Anxiety and author of Freeing Your Child From Obsessive Compulsive Disorder.

Stephanie Woodrow, LCPC, NCC, recently named an emerging leader by the Anxiety and Depression Association of America, tells Bustle.

Elise Hall, LCSW a clinical social worker with a private practice specializing in the treatment of OCD and anxiety disorders.

Studies sourced:

Hezel, D. M., Simpson, H. B. (2019, January). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343408/.

Five signs you may be living with anxiety

When checks revealed no physical health problems, Robert’s GP determined the symptoms as panic attacks, a common sign of an anxiety disorder.

Says Dr Blashki: “Anxiety, and in particular panic attacks, usually involve significant physical symptoms such as a racing heart, breathlessness, dizziness, a choking feeling, a churning stomach, chest pains.”

He adds: “The symptoms can come on quite suddenly and can escalate within minutes. Not surprisingly, someone experiencing a panic attack is often worried they’re going to pass out, embarrass themselves, or even die — so it can be quite a terrifying experience.”

Worry that’s out of proportion

When worry becomes your constant companion, you could be experiencing an anxiety condition.

Unrelenting worry with no single focus and a tendency to escalate into catastrophic thoughts is a red flag, says Dr Blashki.

“People who are experiencing social anxiety get very caught up worrying about what other people think of them and imagine that others are observing and criticising them,” he says.

“People with Generalised Anxiety Disorder are very prone to catastrophic thinking and imagining the worst possible outcome of any situation.”

He adds: “The psychological approach called cognitive behavioural therapy targets negative thinking and helps people to put these thoughts into perspective.”

Obsessive thinking

Anxiety conditions can provoke persistent, distressing thoughts that can make you feel stuck in a loop.

Natasha*, 35, had started lying awake nightly, ruminating over perceived slights at work. She’d fixate on answered emails or texts. Had she caused offence? Was her job in danger?

Her obsessive brooding, disrupting her sleep and mood, turned out to be a key symptom of an undiagnosed anxiety condition.

Obsessive thinking can also indicate a specific type of anxiety condition: Obsessive Compulsive Disorder (OCD).

Says Dr Blashki: “The central feature of OCD is recurring intrusive thoughts that can lead to significant disability and lost quality of life.

“Common themes for obsessions include cleanliness, safety and checking, counting or hoarding and sometimes sexual or religious/moral issues.”

He adds: “OCD usually manifests in the need to repeat activities like checking or hand washing, to obtain a sense of relief.”

Avoidance

Lisa* froze outside her office one day. “I just couldn’t move my feet forward,” she says. “I turned around, went home, and called in sick.”

After increased absences from work, Lisa sought help. With a diagnosis from her GP, she was able to manage her anxiety condition.

“Avoidance and withdrawal from anxiety-provoking situations is very common,” says Dr Blashki, “and unfortunately when anxiety is not addressed, the situations in which a person feels safe tend to become increasingly restricted.”

He adds: “People sometimes develop a secondary condition we call agoraphobia, where they avoid any place where they might feel trapped, embarrassed or helpless.”

Unwanted flashbacks

Post-traumatic stress disorder (PTSD) is an anxiety condition that can occur after someone experiences a traumatic event, such as war, an accident, assault or natural disaster.

“Often the person experiences upsetting memories, flashbacks or dreams,” says Dr Blashki. “Or they

might find they get very distressed when something reminds them of the event.”

“People with PTSD might find themselves always on guard and vigilant, easily startled and easily irritated. Some also find that they feel emotionally detached and disconnected,” he adds.

If you think you or someone you know is experiencing symptoms of anxiety, reach out to Beyond Blue for support. Visit https://www.beyondblue.org.au/ to learn more.

*Real names weren’t used for anonymity

Common Misconceptions About OCD and Its Symptoms

Common symptoms of OCD include (but are not limited to) anxiety, intrusive thoughts, or images that may be violent or disturbing and don’t go away quickly, excessive reassurance-seeking, avoidance, a fear of losing control, and a need for things to feel “just right.”

Are there different types of the disorder?

OCD is a wily disorder that can take on many different forms or subtypes. Sometimes people will suffer from multiple subtypes of the disorder throughout their lives. Different types include contamination, harm OCD, pure O, scrupulosity or religious OCD, relationship OCD, and postpartum OCD.

Contamination is one of the most common types of OCD. People with OCD who fixate on contamination are likely to wash their hands or shower far more than is necessary to maintain health and hygiene and will avoid coming into contact with certain things that they fear may be contaminated. Contamination is the sort of OCD that is usually depicted in pop culture, which Syzmanski says sometimes leads people to think that compulsions like washing and cleaning are the only symptoms of OCD.

Then there’s harm OCD. “I see a lot of harm OCD,” Maxwell says, which consists of fears that the person will cause harm to others or themselves, or that serious harm will be inflicted on them by others, and so they try to be hypervigilant of their thoughts, words, and behavior in order to prevent doing damage. Maxwell adds that in her work with children who have OCD, it’s common for them to have a fear of being kidnapped, and the accompanying compulsive behaviors are elaborate bedtime rituals in which the child will repeatedly check door locks, windows, alarm systems, and seek reassurance from their parents that they will be okay.

Some OCD patients don’t suffer from compulsive behaviors at all. In cases where someone has pure O — meaning pure obsessions — they will experience disturbing, obsessive thoughts and images, but do not carry out rituals in order to quell their fears.

How long does it take to get diagnosed?

For a variety of reasons, it can often take a really long time for people with OCD to get a proper diagnosis. According to a 2015 article published in the journal American Family Physician, it typically takes 11 years between the onset of OCD symptoms and receiving treatment.

According to Syzmanski, one of the main reasons why it can take such a long time to get a proper diagnosis is due to the fact that people with OCD are often ashamed of their thoughts and behaviors. “Because people [with OCD] recognize, for the most part, that what they’re feeling and their behavior is out of the norm and they don’t want to be doing it, they get ashamed and tend to hide and isolate.” People with harm OCD in particular may be convinced that they have committed or are capable of committing serious offenses against others, and will feel tremendous guilt and shame over things they’ve never done or been accused of. If the person isn’t opening up about their symptoms, it can be a lot harder for anyone, even a professional, to notice that they have the disorder.

It’s also the case that even in the medical community, there are a lot of misunderstandings about OCD. Szymanski says that half of the cases of this particular disorder are misdiagnosed by medical professionals.

How is OCD caused?

As is true with many different mental illnesses, researchers have not found a definitive cause, but BeyondOCD.org notes that there is a neurobiological basis for OCD. That is, the brains of people with OCD work differently than the brains of people without it. Further, research shows that it may be caused by a combination of neurobiological, genetic, environmental, and cognitive and behavioral factors. A quarter of people with OCD also have an immediate family member with OCD.

Hope is a key factor in recovering from anxiety disorders: Hope increases in therapy

The concept of hope has long stirred opinion. In the sixteenth century, Martin Luther celebrated its power, claiming “Everything that is done in this world is done by hope.” Two centuries later, Benjamin Franklin warned that “He that lives upon hope will die fasting.” Into the conversation, Gallagher reports that psychotherapy can result in clear increases in hope and that changes in hope are associated with changes in anxiety symptoms.

More than pure philosophy, Gallagher has empirical evidence. His study examined the role of hope in predicting recovery in a clinical trial of 223 adults in cognitive behavior therapy (CBT) for one of four common anxiety disorders: social anxiety disorder, panic disorder, generalized anxiety disorder and obsessive-compulsive disorder.

“In reviewing recovery during CBT among the diverse clinical presentations, hope was a common element and a strong predictor of recovery,” said Gallagher who reports that moderate-to-large increases in hope and changes in hope were consistent across the five separate CBT treatment protocols.

In terms of psychotherapy, hope represents the capacity of patients to identify strategies or pathways to achieve goals and the motivation to effectively pursue those pathways. Significantly, the results of this study indicate that hope gradually increases during the course of CBT, and increases in hope were greater for those in active treatment than for those in the waitlist comparison. The magnitude of these changes in hope were consistent across different CBT protocols and across the four anxiety disorders examined, which underscores the broad relevance of instilling hope as an important factor in promoting recovery during psychotherapy.

“Our results can lead to a better understanding of how people are recovering and it’s something therapists can monitor. If a therapist is working with a client who isn’t making progress, or is stuck in some way, hope might be an important mechanism to guide the patient forward toward recovery,” said Gallagher.

Hope is closely related to other positive psychology constructs, such as self-efficacy and optimism, that have also been shown to have clear relevance to promoting resilience to and recovery from emotional disorders, said Gallagher.

Gallagher is the first author of the paper. The research is part of a larger project examining the efficacy of CBT for anxiety disorders led by David H. Barlow, founder and director emeritus of the Boston University Center for Anxiety and Related Disorders.

Hope is a key factor in recovering from anxiety disorders

IMAGE: University of Houston associate professor of clinical psychology, Matthew Gallagher reports in Behavior Therapy that hope is a trait that predicts resilience and recovery from anxiety disorders.
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Credit: University of Houston

University of Houston associate professor of clinical psychology, Matthew Gallagher, has added his voice to a debate that spans the ages — the importance of hope. Gallagher reports in Behavior Therapy that hope is a trait that predicts resilience and recovery from anxiety disorders.

The concept of hope has long stirred opinion. In the sixteenth century, Martin Luther celebrated its power, claiming “Everything that is done in this world is done by hope.” Two centuries later, Benjamin Franklin warned that “He that lives upon hope will die fasting.” Into the conversation, Gallagher reports that psychotherapy can result in clear increases in hope and that changes in hope are associated with changes in anxiety symptoms.

More than pure philosophy, Gallagher has empirical evidence. His study examined the role of hope in predicting recovery in a clinical trial of 223 adults in cognitive behavior therapy (CBT) for one of four common anxiety disorders: social anxiety disorder, panic disorder, generalized anxiety disorder and obsessive-compulsive disorder.

“In reviewing recovery during CBT among the diverse clinical presentations, hope was a common element and a strong predictor of recovery,” said Gallagher who reports that moderate-to-large increases in hope and changes in hope were consistent across the five separate CBT treatment protocols.

In terms of psychotherapy, hope represents the capacity of patients to identify strategies or pathways to achieve goals and the motivation to effectively pursue those pathways. Significantly, the results of this study indicate that hope gradually increases during the course of CBT, and increases in hope were greater for those in active treatment than for those in the waitlist comparison. The magnitude of these changes in hope were consistent across different CBT protocols and across the four anxiety disorders examined, which underscores the broad relevance of instilling hope as an important factor in promoting recovery during psychotherapy.

“Our results can lead to a better understanding of how people are recovering and it’s something therapists can monitor. If a therapist is working with a client who isn’t making progress, or is stuck in some way, hope might be an important mechanism to guide the patient forward toward recovery,” said Gallagher.

Hope is closely related to other positive psychology constructs, such as self-efficacy and optimism, that have also been shown to have clear relevance to promoting resilience to and recovery from emotional disorders, said Gallagher.

Gallagher is the first author of the paper. The research is part of a larger project examining the efficacy of CBT for anxiety disorders led by David H. Barlow, founder and director emeritus of the Boston University Center for Anxiety and Related Disorders.

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