Prenatal Stress and Psychiatric Symptoms During Early Phases of the CO | IJWH

Introduction

In February 2020, Italy became the first European country to face the Coronavirus Disease 2019 (COVID-19) outbreak. The contagion rapidly spread and, by April 28th 2020, 199,470 people were known to have been infected in Italy.1 Several measures were adopted to limit the spread of the virus and a national lockdown was imposed on March 11th. Then, following a substantial reduction of new cases, restrictions were removed on July 3rd, although personal protective equipment and social distancing were still mandatory.

Alongside the COVID-19 pandemic, a psychiatric epidemic was reported. The possible repercussion of this unusual situation on mental health was identified as a crucial problem since the pandemic onset; in fact, in March 2020, the World Health Organization (WHO) developed recommendations to support psychological well-being during the pandemic.2 The psychological consequences of the COVID-19 outbreak have become a global challenge, particularly for highly vulnerable individuals. Hence, there is a need to identify these population groups and guarantee them appropriate health-care provision.3

Pregnant women are considered at high-risk for severe impact of the pandemic because of their increased susceptibility to distress.4 Knowledge about SARS-COV2 infection and its complications during pregnancy was initially limited and much of it was derived from studies regarding two other coronaviruses, MERS and SARS. There had been no cases of intrauterine maternal-foetal transmission with SARS and MERS, so the likelihood of vertical transmission for SARS-COV2 was considered low.5 At the time of our study, there was a lack of definitive evidence about whether the SARS-COV2 virus may create life-threatening clinical conditions for pregnant women and increase risk of preterm delivery, other adverse birth outcomes, or neonatal morbidity and mortality.6,7 Uncertainty about the potential impacts of the virus and the lack of reliable information are sources of stress that may adversely affect the well-being of mothers and the health and development of their children.8

Furthermore, pregnant women seem to be more vulnerable to anxiety and depression compared to the general population9,10 and they are also at risk to develop obsessive-compulsive disorder (OCD).11 Indeed, several studies have detected an uptick in levels of anxiety and depression in expectant women during the COVID-19 outbreak;12–14 these results are in line with previous studies of mothers-to-be during natural disasters.15 Also, obsessive-compulsive symptoms, which are more common during pregnancy as oppose to other time periods11 are likely to be more prevalent during the COVID-19 pandemic because of infection fears and public health measures emphasizing protective behaviours such as handwashing.16

Stress-related to the pandemic co-occurs with pregnancy-specific stress (PSS), which derives from worries about physical symptoms, bodily changes, and concerns about the baby.17,18 It is well known that PSS can negatively affect birth outcome and development of the child and some evidence demonstrating an association of PSS with clinically relevant anxiety and depressive symptoms.19,20

Problem Statement

Our aim was to assess the role of PSS role together with pandemic-related stress in determining the presence of a selected psychiatric symptomatology. We predicted that pandemic-related stress would be associated with elevated PSS, which in turn would predict higher risk of depression, anxiety, and OCD. In other words, we predicted that PSS would mediate an association of pandemic-related stress with psychiatric symptomatology.

Patients and Methods

A cross- sectional study was carried out to evaluate the pregnancy specific stress, pandemic related stress and clinical outcome in a sample of pregnant women.

Participants

Data were collected between April 22nd and August 31st 2020. This time period encompasses the first (April-May) and second phases (July-August) of the pandemic onset in Italy. Pregnant women were recruited among those receiving outpatient prenatal care at the Gynaecology Clinic of the University Hospital of Udine. The participation in the research was proposed directly by the participant’s physician. Inclusion criteria were current pregnancy, age over 18 years, and Italian fluency. Two hundred fifty-eight women agreed to participate and completed the study questionnaires. All recruited women were volunteers and received no incentives for their participation. The participants filled out the questionnaire in a paper-and-pencil format at the hospital during routine clinical check-ups. All participants provided informed consent. All procedures performed in this study were in accordance with the ethical standards of the 1964 Helsinki Declaration and its subsequent amendments. Approval was granted by the Medical Ethics Committee of Friuli Venezia Giulia region (CEUR-2018-Sper-027-ASUIUD). Written informed consent was obtained from all participants included in the study. The privacy and dignity of the respondents were assured by making all the information anonymous and confidential.

Measures

Data were collected with a questionnaire that gathered background information, COVID-19 exposure, and pregnancy and prenatal care aspects. We also investigated knowledge of the COVID-19 pandemic with a scale consisting of two questions (‘I feel knowledgeable about COVID-19ʹ and ‘I believe I can control not getting COVID-19ʹ). Data concerning pregnancy risk-status were checked by gynaecologists who followed the women during pregnancy (S.A. and D.M.). Additionally, we administered the following self-report instruments to measure stress and psychiatric symptoms.

To evaluate stress among pregnant women related to the COVID-19 pandemic, we used the Pandemic-Related Pregnancy Stress Scale (PREPS).21 The instrument includes 15 items that are scored on a scale from 1 (“Very Little”) to 5 (“Very Much”). It comprises three internally consistent scales: Preparedness Stress (PS, 7 items), Prenatal Infection Stress (PIS, 5 items), and Positive Appraisal (PA, 3 items). The PREPS-PS is related to feeling unprepared for delivery and postpartum, PREPS-PIS evaluates the stress related to fear of perinatal infection, and PREPS-PA assesses strategies for coping with pandemic-related stress.21,22 In this study we focused on PREPS stress scales and we only included PREPS-PA as possible covariate. We used the Italian version of the PREPS adapted by our research group (Penengo et al, 2021 accepted), that showed acceptable-to-good internal consistency for PS (α=0.760), PIS (α=0.857), and PA (α=0.747) scales.

To assess PSS, we used a revised version of the Prenatal Distress Questionnaire (NuPDQ), developed by Lobel and colleagues.23 The instrument comprises 17 items ranging from 0 (“Never”) to 2 (“Very Often”); the total score is the sum of each item and range from 0 to 34. This instrument showed good reliability (α=0.55–0.79) in various studies.18 We used the Italian version validated by our group.24

Anxiety symptoms were evaluated through the General Anxiety Disorder-7 (GAD-7).25 A total score of seven or above is considered a clinically meaningful level of anxiety symptoms during pregnancy.26 The instrument showed good internal consistency (α=0.89),26 and was well validated in pregnant women.27

To screen symptoms of major depressive disorder, we used the Patient Health Questionnaire-2 (PHQ-2), a short form of the PHQ-9 questionnaire.28,29 A score of 3 or above is considered the cut-off for depression. The internal consistency of PHQ-2 resulted good (α=0.83),30 and it resulted to be an efficient screening tool for depression in pregnant women.31

Lastly, to assess the presence or absence of obsessive-compulsive symptoms, we used the OCD Screening, derived from the Structured Clinical Interview for DSM-5,32 which consists of two questions. The screening assesses the presence of obsessive-compulsive symptoms when women responded “Yes” to both of the questions.

Data Analysis

We considered potential covariates of the psychiatric symptomatology outcome variables in various domains: positive coping, as measured with PREPS (PA scale, 1–5); pregnancy status (i.e., pregnancy has been defined as at-risk during clinical check-ups, no/yes; in the 3rd pregnancy trimester, no/yes; first child, no/yes); COVID-19 pandemic (three measures; i.e., assessment conducted in the 2nd Italian pandemic phase, no/yes; level of perceived knowledge about pandemic, 1–5; having had rescheduled appointments in prenatal care, no/yes); general personal information (two measures; i.e., age in years; education in schooling years); financial status (three measures; i.e., not being currently employed, no/yes; financial status, low/medium/high; having suffered from recent loss of income, no/yes); general well-being (seven measures; i.e., history of emotional/psychiatric problems, no/yes; having experienced emotional/physical abuse, no/yes; having a chronic medical condition, no/yes; level of perceived support from family/friend, 1–5; level of perceived support from partner, 1–5; level of healthy activities carried out, 1–5; living alone, no/yes).

All the covariates were used to fit a complete regression model for each outcome (i.e., GAD-7 score, 0–21; PHQ-2 score, 0–6; OCD positive screening, no/yes). Then, backward selections based on Akaike’s Information Criterion were adopted to identify a set of significant covariates for each outcome. Further analyses were replicated using both complete and selected covariates and without covariates. For regression analyses, model statistical significance, parameter estimates, and the coefficient of determination (R2 or McFadden’s pseudo-R2) were calculated. Variance inflation factors below the square root of 2 were accepted.

A series of mediation analyses were conducted to estimate the mediation of NuPDQ in the regressions of psychiatric symptoms on the two PREPS stress scales. Estimates were made using a non-parametric bootstrapping method (with 10,000 replication samples).33 Average Causal Mediation Effect (ACME) was calculated as a measure of indirect effect, together with percent mediated. Average Direct Effect (ADE) and total effect were also calculated. Only models with a statistically significant association between the independent variable (PREPS) and both the dependent variables (GAD-7; PHQ-2; OCD) and mediator (NuPDQ) were considered evidence of mediation.

Mean-substitution was preferred to manage missing data in multivariate analyses. All analyses were conducted using R-4.0.3.34

Results

Sample Characteristics

There was a similar percentage of women in different pandemic phases (1st: April-May 2020/2nd: July-August 2020), pregnancy periods (Early: first and second trimesters/Late: third trimester), and pregnancy risk-levels (Low-risk/High-risk; Fisher’s exact test for count data, all with: OR ≤ 1.519, p≥0.140). Frequencies are reported in Table 1.

Table 1 Total Sample (N=258). Distributions by 2020 Pandemic Phase in Italy, Pregnancy Period and Pregnancy Risk Status

The mean age of participants was 32.5 ±5.12 years, the mean years of education were 15.1 ±3.60; most women were married or in a stable cohabiting relationship (251 women, 99.2%). 37.9% of the participants lived in centres of more than 50,000 inhabitants, and 88.0% of them had access to the outdoors during the period of pandemic-related movement restrictions. The majority of the sample were Caucasian women (95.7%). Only two women were diagnosed with COVID-19 and eight others had any indirect contact with the disease. Sociodemographic and general characteristics of the sample are reported in Table 2, together with participants’ scores on study instruments.

Table 2 Total Sample (N=258). Sociodemographic and Clinical Description. Continuous Measures are Reported in Part A. Binary Measures are Reported in Part B

32.6% of participants scored above the cut-off for anxiety on the GAD-7 (i.e., score ≥7, without differences between pandemic phases (p=0.780), period of pregnancy (p=0.394), or level of pregnancy risk (p=0.456). In comparison, only 4.8% of the sample had high scores for depression (PHQ-2 score ≥3), also without any differences between pandemic phases (p=0.555), period of pregnancy (p=0.766), or pregnancy risk (p=1.000). Finally, 11.2% of the sample had a positive score on the obsessive-compulsive screening, also without any differences between the three variable groups (pandemic phases p=0.548; period of pregnancy p=0.544; pregnancy risk p=0.056).

There were few differences in other participant characteristics between those in the first or second phases of the pandemic. Compared to women who participated in the first phase, a greater portion of participants in the second phase reported below-average financial status (18.7% vs 8.1%; p=0.025; OR=2.590) and fewer reported average financial status (77.6% vs 88.3%, p=0.042; OR=0.461. Moreover, there were few differences between women with high-risk and low-risk pregnancies: the mean age was higher for women with high-risk pregnancies (p=0.014) and they also reported more frequent chronic medical conditions (p0.001). Lastly, we found that a greater portion of women in the 3rd trimester of pregnancy reported high financial status (p=0.046), and a higher level of pregnancy-specific stress (p=0.008) than women earlier in pregnancy. Women having their first child, were more often younger (p=0.004), more frequently employed (p=0.022), and showed a greater level of healthy activity (p=0.014).

Multiple Linear/Logistic Regressions

Table 3 reports the list of selected covariates for each outcome (detailed results are reported in supplementary materials; Tables S1 and S2). The GAD-7 model was statistically significant (R2=0.203, adjusted to 0.135; F19,222=2.982, p0.001) and four predictors were backward-selected (R2=0.178, adjusted to 0.164; F4237=12.84, p0.001). Similarly, the PHQ-2 model (R2=0.174, adjusted to 0.105; F19,228=2.53, p=0.001) resulted in selection of five predictors (R2=0.150, adjusted to 0.133; F5242=8.57, p0.001). Therefore, mediation analyses were conducted using selected covariates for GAD-7 and PHQ-2 scores. The OCD model was not statistically significant (pseudo-R2=0.150; χ219=26.25, p=0.123), hence the mediation analysis for positive OCD screening was conducted without covariates.

Table 3 Multiple Linear Regressions with GAD-7 Scores and PHQ-2 Scores as Dependent Variables. Standardized Data and Coefficients are Reported with Their 95% Confidence Interval. See Table S1 and S2 for Details

Mediation Analysis

Figures 1–3 show the analyses of the effects (ADE and ACME) of the pandemic-related stress scales (PREPS-PS and PREPS-PIS), with the mediation of NuPDQ, on the psychometric scales, as described in the methods section (detailed results are reported in supplementary materials; Tables S3 and S4).

Figure 1 Mediations of pregnancy-specific stress (NuPDQ) in regressions of anxiety score (GAD-7) on pandemic-related stress measures (PREPS-PS and PREPS-PIS). Mediation coefficients are reported with 95% confidence interval between square brackets. Selected covariates are listed. See Tables S1 and S4 for details.

Abbreviations: ADE, Average Direct Effect; GAD-7, General Anxiety Disorder, 7-items, questionnaire; NuPDQ, Revised Prenatal Distress Questionnaire; PIS, Prenatal Infection Stress scale; PREPS, Pandemic-Related Pregnancy Stress Scale; PS, Preparedness Stress scale; X, Arrow not statistically significant after mediation.

Figure 2 Mediations of pregnancy-specific stress (NuPDQ) in regressions of depression score (PHQ-2) on pandemic-related stress measures (PREPS-PS and PREPS-PIS). Mediation coefficients are reported with 95% confidence interval between square brackets. Selected covariates are listed. See Tables S2 and S4 for details.

Abbreviations: ADE, Average Direct Effect; NuPDQ, Revised Prenatal Distress Questionnaire; PHQ-2, Patient Health Questionnaire, 2-items; PIS, Prenatal Infection Stress scale; PREPS, Pandemic-Related Pregnancy Stress Scale; PS, Preparedness Stress scale; X, arrow not statistically significant after mediation.

Figure 3 Mediations of pregnancy-specific stress (NuPDQ) in regressions of screening for obsessive-compulsive problems on stress for prenatal infection (PREPS-PIS). Mediation coefficients are reported with 95% confidence interval between square brackets.

Abbreviations: ADE, Average Direct Effect; NuPDQ, Revised Prenatal Distress Questionnaire; OCD, positive screening for Obsessive-Compulsive Disorder; PIS, Prenatal Infection Stress scale; PREPS, Pandemic-Related Pregnancy Stress Scale; X, Arrow not statistically significant after mediation.

The GAD-7 score was significantly predicted (p≤0.001) by all the stress measures after correcting for selected covariates (NuPDQ: β=+0.294, R2=0.259; PREPS-PS: β=+0.197, R2=0.216; PREPS-PIS: β=+0.216, R2=0.224). When included as a mediator (Figure 1), NuPDQ completely mediated the effect of PREPS-PS (50.2% [20.05%, 135.37%]; ADE: p=0.133) and partially mediated the effect of PREPS-PIS (33.6% [14.30%, 74.26%]).

Similarly, with selected covariates, all the stress measures statistically significantly predicted the PHQ-2 score (NuPDQ: β=+0.273, R2=0.220; PREPS-PS: β=+0.273, R2=0.196; PREPS-PIS: β=+0.159, R2=0.175). For PHQ-2 (Figure 2), the NuPDQ score partially mediated the effect of PREPS-PS (39.8% [15.19%, 94.01%]) and totally that of PREPS-PIS (45.2%, [16.86%, 140.67%], ADE: p=0.134).

Finally, a positive screening for OCD was predicted by NuPDQ (OR=1.80, p=0.003, pseudo-R2=0.051, χ21=8.87, p=0.003) and PREPS-PIS (OR=1.80, p=0.006, pseudo-R2=0.046, χ21=8.09, p=0.004) scores, but not by PREPS-PS. NuPDQ (Figure 3) completely mediated the effect of PREPS-PIS on OCD screening (25.2%, [1.89%, 94.51%], ADE: p=0.053).

Discussion

This study illustrates the psychological experience of pregnant women at the onset of the COVID-19 pandemic in Italy. Almost a third of the sample reported anxiety levels compatible with a clinical disorder (32.6% of the sample), and a relevant percentage was positive for screening obsessive-compulsive problems (11.2%). In contrast, less than 5% of the sample had clinically relevant depression scores. The observed frequencies suggest that the sample is mainly characterized by anxiety problems. However, depression and anxiety are typically comorbid during pregnancy, and high anxiety is a risk factor for antenatal depression.35 Study findings suggest that a global pandemic may create unique circumstances that result in different patterns and prevalence of psychopathology among pregnant women, with particular impact manifested in their anxiety.36–38 About half of the participants that were positive for obsessive-compulsive symptoms also indicated anxiety problems. The frequency of high anxiety was also higher than that reported for the Italian general population during the pandemic: Mazza and colleagues found high anxiety levels in 7.2% of their sample, and very high anxiety levels in 11.5%.39

A recent meta-analysis assessed the psychological impact of COVID 19 pandemic in pregnant women. It included 19 papers from ten different countries and showed an increased prevalence of anxiety and depression among expectant mothers, with an overall reported rate of 42% and 25% respectively.40

Moreover, a longitudinal evaluation of pregnant women during quarantine showed a more pronounced increase in anxiety, depression and negative affect compared to non-pregnant women, suggesting that being pregnant may be consider a risk factor for psychopathological consequences of the pandemic.41

Samples recruited in the first and second pandemic onset phases were quite homogeneous. Nevertheless, a few differences emerged between April-May and July-August. For example, we found lower financial status among participants in the second phase. Low socioeconomic status is a well-known risk factor for psychological disorders, in particular, depression.42,43 Studies of the SARS outbreak in 200344 demonstrated that income loss resulting from quarantines and lockdowns, when people are unable to work, can be a risk factor for poor mental health,45 especially depressive symptoms.46 Consistent with these findings, in our sample, current unemployment was related to clinical levels of depression. We also detected increased levels of anxiety in unpartnered women. Living alone is a significant determinant of loneliness, a condition that can increase the risk of mental impairment leading to anxiety, depression, and even suicidal ideation.47

Higher levels of anxiety and depression were also associated with previous emotional or psychiatric problems. A recent Italian study detected a greater level of COVID-19 concerns and anxiety among expectant mothers with a history of psychiatric disturbances.48 Similarly, many studies have found that a history of psychiatric illness increases the risk of antenatal onset of depression.49

Lastly, knowledge about COVID-19 was positively related to a higher level of anxiety and depression, a result in contrast with several studies that associated the absence of information about COVID-19 infection and pregnancy with a greater level of anxiety and distress among childbearing women.36,50,51 Nevertheless, our data need to be understood in the context of the uncertainty and constantly evolving knowledge about the mechanism of transmission of the virus and its potential consequences that were typical during the onset of the pandemic when this study was conducted.52

Apart from the factors that were associated with poorer mental health, we found that healthy activities seem to have a protective role against anxiety and depression symptoms, also as shown in previous research.53,54 In particular, many studies in the general population and in pregnant women report a positive impact of healthy behavior on depressive symptoms, corroborating the beneficial relationship between healthy lifestyles and lower levels of depression that we found.53,55,56

As we predicted, stress related to the pandemic co-occurred with stress that is unrelated to the pandemic but focused on pregnancy itself. Both types of stress were potent predictors of poorer mental health, with distinct patterns of association for each of the three outcomes. For example, women experiencing greater stress involving fears about perinatal COVID-19 infection had higher anxiety, and this association occurred in part because these women also experienced greater distress unassociated with the pandemic, specific to being pregnant. Previous studies concerning the SARS outbreak in 200357,58 similarly showed that fear of becoming infected was related to greater anxiety in pregnant women. Additionally, in the present study, women who reported higher pandemic-related stress involving concerns that they would be unprepared for childbirth or the postpartum also experienced greater anxiety; this association was entirely explained by the association of this type of pandemic-related stress with pandemic unrelated, pregnancy-specific stress (PSS). Similarly, PSS entirely explained the association of perinatal infection stress with depressive symptoms and partially explained the association of preparedness stress with this mental health outcome. Feeling unprepared for birth or postpartum due to the pandemic can lead to demoralization and hopelessness and hence to depressive symptoms.59

Lastly, obsessive-compulsive symptoms were also predicted by higher stress involving fears of perinatal infection, and this association was explained by higher PSS among women who reported this type of pandemic-related stress. This result parallels a previous study16 that found in a sample of university students that the fear of COVID-19 infection was strongly correlated with scores on a measure of OCD, suggesting that such fear, together with anxiety and pandemic-induced quarantine, is a risk factor for obsessive-compulsive symptoms.

Given the pivotal role of PSS in mediating many of the associations of pandemic-related stress with anxiety, depressive, and obsessive-compulsive symptoms, study results suggest that it is essential not only to reduce stressful conditions related to the pandemic, but also to alleviate the pregnancy-specific conditions that create distress for women whether in times of a pandemic or not.

Limitations and Strengths

A major limitation of this study is the cross-sectional design, thus we cannot confirm causal relationships between measures. However, we did find scientifically plausible associations using well-validated instruments, in many cases corroborating findings of comparable research. Another strength is the evaluation of multiple dimensions of mental health and numerous possible risk factors. The current pandemic has created numerous stressors for pregnant women, whose physical and psychological vulnerability underscores the need to examine a variety of potential mental health consequences and the range of risk factors that may affect them.

Conclusion

The present study highlights how the COVID-19 pandemic is influencing the mental health of Italian expectant mothers and indicates that a substantial portion of them are experiencing high anxiety. In our analysis, pandemic-related stress predicts the development of anxiety, depressive, and obsessive-compulsive symptoms. These associations are partially mediated by experiencing more of the type of stress that pregnant women commonly experience, which includes stress related to their concerns about their health and changes to their body, about impending delivery, and about the challenges they are about to face as the parent of a new-born. Hence, our results emphasize the importance of strategies to reduce such pregnancy-specific stress, as well as to diminish the stress that has arisen for pregnant women due to the COVID-19 pandemic. Anxiety, depression, and OCD symptoms in pregnant women have been shown to elevate risk for a variety of adverse maternal, foetal, and infant outcomes.60–65 Identifying risk factors for poor mental health and promptly intervening is fundamental to stem detrimental consequences in the short term, as well as to prevent their longer term harms to women and children.

Olympic boxer Ginny Fuchs faces her toughest fight against obsessive-compulsive disorder

Ginny Fuchs is used to fighting difficult battles as one of the best flyweight boxers in the world. She is calm and focused when in the ring, but the 2021 Olympian’s most challenging fight comes from within her own mind.

Fuchs was diagnosed with obsessive-compulsive disorder (OCD) in eighth grade, and she said her symptoms have progressively worsened as she has gotten older. Fuchs’ OCD manifests as a fear of contamination: If she feels that something is contaminated or unclean, she excessively cleans it until the feeling is satisfied. 

“If I’m washing my hands, I might be at the sink for 30 minutes, and I might have to use two different soaps because my brain is telling me, ‘That’s not good enough. It’s not clean enough,’” Fuchs told USA TODAY Sports. “I can go through bottles of soap, bottles of shower gel. When I take a shower, I use multiple washcloths and sponges. Once my mind says something is contaminated, it’s very hard for me to feel like it’s all right.”

What you should know about OCD | The New Times | Rwanda

The World Health Organization (WHO) ranks obsessive compulsive disorder (OCD) as one of the top ten most disabling illnesses.

According to Yvonne Uwamahoro, a counsellor at Mental Health Hub, Kicukiro, OCD is an anxiety disorder characterised by uncontrollable, unwanted thoughts and ritualised, repetitive behaviour you feel compelled to perform.

If you have OCD, you probably recognise that your obsessive thoughts and compulsive behaviour are irrational but even so, you feel unable to resist them and break free, she says.

Causes and risk factors

Uwamahoro says that genetic factors could be the cause as genes may play a role in OCD for some. OCD tends to run in families. Having a relative with OCD increases the risk of having it.

“OCD often occurs in people who have other mental health illnesses. This can include, anxiety disorders, depression, attention deficit hyperactivity disorder, and substance abuse,” the counsellor notes.

She explains that pregnancy and postpartum period can lead to OCD, this is because hormones can trigger symptoms. OCD symptoms may worsen with pregnancy. OCD after giving birth can include intense worry over the baby’s well-being.

An example of common obsessions is fear of germs or dirt. Photo: Net

Uwamahoro says OCD is most common in older teens or young adults. It can begin as early as pre-school age and as late as age 40. Stress can make OCD symptoms appear. It is often linked to major life changes, such as the loss of a loved one, divorce, relationship issues, problems in school, or abuse, period of uncertainty, and pandemic. 

According to the Centers for Disease Control and Prevention, having OCD means having obsessions, compulsions, or both. Examples of obsessive or compulsive behaviours include, unwanted thoughts, impulses, or images that occur over and over and which cause anxiety or distress.

The National Institute of Mental Health (NIH) states that the symptoms may come and go, ease over time, or worsen. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.

“Although most adults with OCD recognise that what they are doing doesn’t make sense, some adults and most children may not realise that their behaviour is out of the ordinary. Parents or teachers typically recognise OCD symptoms in children,” Uwamahoro says.

She adds that teenagers and young adults with a mental health background in their families, or are living in a stressful environment, are at risk.

Complications

Uwamahoro says that OCD can affect one’s relationship with others, work or school effort, and general wellness. For example, poor concentration is common, usually as a result of being distracted by upsetting and intrusive thoughts (obsessions).

One can fail to do their tasks because they are dealing with non-stop thoughts, Uwamahoro adds.

OCD can also cause a child to become avoidant of situations that may provoke intrusive thoughts; for example, avoiding areas that they believe to be contaminated, like school toilets.

The mental health counsellor highlights that young people who fear being poisoned may avoid any contact with science laboratories given the potential for chemicals to be nearby. In severe cases, a person with OCD may struggle to leave the house and may be unable to attend school altogether or interact with others freely.

Prevention and treatment

 Mental health experts say that if you think you have OCD, see a Doctor, a psychiatrist, or mental health professional. The diagnosis process will likely include a physical exam to see if your symptoms are due to a health condition. Blood tests to check your blood count, how well your thyroid works, and any drugs or alcohol in your system. A psychological test or evaluation about your feelings, fears, obsessions, compulsions, and actions, can also be done.

Uwamahoro points out that OCD usually doesn’t happen all at once. Symptoms start small, and to someone, they can seem to be normal behaviours. They can be triggered by a personal crisis, abuse, or something negative that affects one a lot, like the death of a loved one. It’s more likely if people in one’s family have OCD or another mental health disorder, such as depression or anxiety.

She adds that examples of common obsessions often have a theme, such as, fear of germs or dirt, fear to touch things other people have touched, like doorknobs. Or fear to hug or shake hands with others.

Or, one may feel stressed when objects are out of place, one may find it hard to leave home until they’ve arranged things in a certain way, they may also have excessive doubt or fear of making a mistake. They may check repeatedly to make sure kitchen appliances are turned off or if doors are locked.

The International OCD Foundation states that OCD treatment can be difficult, and requires a lot of courage and determination. Having a support network to talk to during treatment can make all the difference, which is why accessing a support group in your area is necessary.

“Treatment for most OCD patients should involve Exposure and Response Prevention (ERP) and medication. About seven out of ten people with OCD will benefit from either medication or ERP,” The International OCD Foundation states. 

editor@newtimesrwanda.com

Anxiety at night: Causes, remedies, and more

The following treatment options can help a person manage nighttime anxiety:

Therapy

Therapy focuses on addressing the source of anxiety and helping a person develop effective coping skills.

The American Psychological Association reports that therapy is often more effective than medication. This may be because therapy helps a person identify the cause of the problem and address it in a constructive way.

Therapy often works best alongside medication, as medication can offer some immediate relief, allowing a person to focus on the therapy.

Several different therapies can be effective for anxiety, including cognitive behavioral therapy (CBT) and exposure therapy.

Medication to manage anxiety

Anxiety medications can change the body’s physical response to anxiety, helping a person feel less anxious.

Antidepressants

Antidepressants affect chemical messengers, or neurotransmitters, in the brain. They can help stabilize a person’s mood or alleviate stress.

Antidepressants can take some time to begin working. A person should give the medication a chance before deciding whether it is effective.

Benzodiazepines

Benzodizaepines are the most common type of anti-anxiety medication. These drugs tend to begin working almost immediately.

Benzodiazepines bind to the neurotransmitter gamma aminobutyric acid (GABA). This helps slow down activity in the brain, thereby helping a person feel less anxious. However, these drugs come with risks that a person should discuss with their doctor first.

Beta blockers

Beta-blockers are medications that people ordinarily use to treat high blood pressure. However, doctors sometimes prescribe these drugs to help alleviate the physical symptoms of anxiety.

Sleep medications

Sleeping pills may help people fall asleep faster, thereby reducing nighttime restlessness. However, the American Academy of Sleep Medicine states that sleeping pills only reduce the length of time it takes to fall asleep by 8 to 20 minutes.

Sleeping pills can also be addictive, so it’s safest to try other interventions first. People who do use sleeping pills should:

  • take the pills only when needed
  • take the pills for the shortest possible time
  • avoid combining the pills with any other drugs, including alcohol

Patterns of Genetic Mutations Linked with Obsessive-Compulsive Disorder in Humans

Researchers headed by a team at Columbia University Vagelos College of Physicians and Surgeons have linked distinct patterns of genetic mutations with obsessive-compulsive disorder (OCD) in humans. Reporting in Nature Neuroscience on their analysis of exome sequencing data from more than 1,000 individuals with OCD, the scientists say their findings “… support a contribution of rare damaging coding variation to OCD risk.” They suggest the work confirms the validity of targeting specific genes as a potential treatment approach for OCD, and also points to new avenues of study for the commonly debilitating condition.

Senior study author David Goldstein, PhD, director of the Institute for Genomic Medicine at Columbia, and colleagues reported on their study in a paper titled, “Exome sequencing in obsessive-compulsive disorder reveals a burden of rare damaging coding variants.” The multi-institution collaboration also included scientists from the University of North Carolina at Chapel Hill, the David Geffen School of Medicine in Los Angeles, Harvard Medical School, and SUNY Downstate Medical Center in Brooklyn.

OCD is a neuropsychiatric condition characterized by persistent, intrusive thoughts (obsessions) and repetitive, intentional behaviors (compulsions), the authors explained. The condition, which affects 1–2% of the population, commonly runs in families, and genes are known to play a large role in determining who develops the disease. “ … Evidence from family-based studies supports a genetic contribution to the disorder,” the team wrote. But while strongly acting mutations have been hypothesized to exist in OCD, statistically reliable evidence has been difficult to obtain.

Goldstein stated, “Many neurological diseases are influenced by strongly acting mutations which can cause disease by themselves. These mutations are individually very rare but important to find because they can provide a starting point for the development of therapeutics that target precise underlying causes of disease.”

Most previous studies on the genetics of OCD have used a “candidate gene” approach, in which researchers focus on plausible genes that might be involved in pathogenesis and look for genetic signatures of risk. Although that approach has had some successes, it can lead to challenges in statistical interpretation and can miss unexpected genes. As a result, both funding agencies and the pharmaceutical industry increasingly focus on genome-wide analyses that can securely implicate genes in disease risk.

But as the researchers noted, “Genome-wide association studies of common single-nucleotide polymorphisms (SNPs) have not found variants that were associated with OCD at the genome-wide level of statistical significance, likely owing to insufficient sample size.” Goldstein further suggested, “The solution to the problem is to study all the genes in the genome at the same time and ask whether any of them have significant evidence of influencing risk. That had not been done yet at scale in OCD.”

In collaboration with Gerald Nestadt, MBBCh, a psychiatrist at Johns Hopkins University with access to a cohort of OCD patients, Goldstein’s team combined high-throughput sequencing and computational biology techniques to identify relevant genes anywhere in the genome. The investigators looked at genes that encode protein using whole exome sequencing in 1,313 OCD patients, and compared them to similarly large control groups.

The analysis identified a strong correlation between OCD and rare mutations, particularly in a gene called SLITRK5 that had been previously linked to OCD in candidate-gene studies. “SLITRK5 is a member of the SLITRK gene family, which influences excitatory and inhibitory synapse formation,” the authors wrote. Interestingly, they continued, “Slitrk5-knockout mice have been described as having increased ‘OCD-like’ behaviors, including elevated anxiety and excessive grooming … In human samples, a burden of SLITRK5 coding variants that influence synapse formation in vitro has previously been described in OCD cases relative to controls.” The study also identified a specific pattern of variation in other genes. “Across the exome, there was an excess of loss of function (LoF) variation specifically within genes that are LoF-intolerant.” As Goldstein further stated, “When you look at genes that do not tolerate variation in the human population, those are the genes most likely to cause disease, and with OCD, we see an overall increased burden of damaging mutations in those genes compared to controls. That’s telling us that there are more OCD genes to be found and where to find them.”

The authors concluded, “This study is, to our knowledge, the most comprehensive cataloguing of contributions to OCD risk from rare damaging coding SNVs [single nucleotide variants] and indels thus far. Its findings suggest that, like the genetic architecture of other neuropsychiatric disorders, OCD involves contributions to overall risk from these variants.”

Goldstein expects that the new data on SLITRK5 will encourage pharmaceutical companies and translational researchers to develop drugs that target this gene. “OCD is a disabling disorder that is twice as common as schizophrenia,” said H. Blair Simpson, MD, PhD, professor of psychiatry at Columbia University Vagelos College of Physicians and Surgeons and director of the Center for OCD Related Disorders at New York State Psychiatric Institute, who was not involved with the new study. Two available treatments, serotonin reuptake inhibiting drugs and cognitive-behavioral therapy, are highly effective, Simpson noted, but only work on about half of patients. “Thus, these genetic findings are very exciting; they indicate that the promise of precision medicine could include OCD, ultimately transforming how we diagnose and treat this disorder.”

Healthline Exposure Therapy for Anxiety: What to Expect and Effectiveness 2 days ago

In exposure therapy, a person is exposed to a situation, event, or object that triggers anxiety, fear, or panic for them. Over a period of time, controlled exposure to a trigger by a trusted person in a safe space can lessen the anxiety or panic.

There are different kinds of exposure therapies. They can include:

  • In vivo exposure. This therapy involves directly facing the feared situation or activity in real life.
  • Imaginal exposure. It involves vividly imagining the trigger situation in detail.
  • Virtual reality exposure. This therapy can be used when in vivo exposure isn’t realistic, like if someone has a fear of flying.
  • Interoceptive exposure. This therapy involves purposefully triggering a physical sensation that is feared, but harmless.

A 2015 research review showed that within those kinds of exposure therapies there are different techniques like:

  • Prolonged exposure (PE). This includes a combination of in vivo and imaginal exposure. For example, someone might repeatedly revisit a traumatic event by visualizing it, and talking about it with a therapist simultaneously, and then discussing it to gain a new perspective about the event.
  • Exposure and response prevention (EX/RP, or ERP). Typically used for people with obsessive compulsive disorder (OCD), this involves doing exposure homework, such as touching something considered “dirty,” and then refraining from performing the compulsive behavior that is triggered from the exposure.

Generalized anxiety

Treatment for generalized anxiety disorder (GAD) can include imaginal exposure and in vivo, but in vivo exposure is not as common. The 2015 research review above showed that cognitive behavioral therapy (CBT) and imaginal exposure improved general functioning in people with GAD compared to relaxation and nondirective therapy.

There is not a lot of research with exposure therapy and GAD, and more is needed to further explore its effectiveness.

Social anxiety

In vivo exposure is typically used for people with social anxiety. This can include things like going to a social situation and not avoiding certain activities. The same 2015 research review above showed that exposure with or without cognitive therapy may be effective in reducing symptoms of social anxiety.

Driving anxiety

Virtual reality exposure therapy has been used to help people with a driving phobia. A small 2018 study found that it was effective in reducing driving anxiety, but more research still needs to be done with this specific phobia. Other therapies may need to be used alongside exposure therapy.

Public speaking

Virtual reality exposure therapy has been found to be effective and therapeutic to treat anxiety about public speaking for both adults and teens. One small 2020 study found that there was a significant decrease in self-rated anxiety about public speaking after a 3-hour session. These results were maintained 3 months later.

Separation anxiety

Separation anxiety disorder is one of the most common anxiety disorders in children. Exposure therapy is considered the top treatment for it. This involves exposing the child to feared situations and, at the same time, encouraging adaptive behavior and thinking. Over time, the anxiety lessens.

Obsessive compulsive disorder (OCD)

Exposure and response prevention (ERP) uses imaginal and in vivo exposure and is often used to help treat OCD. In vivo exposures are done in the therapy session as well as assigned for homework, and the response prevention (not engaging in compulsive behaviors) is part of that. An individual lets the anxiety decrease on its own instead of performing the behaviors that would get rid of the anxiety. When in vivo exposure is too hard or impractical, imaginal exposure is used.

While a 2015 research review showed that ERP was effective, ERP is comparable to cognitive restructuring alone and ERP with cognitive restructuring. Exposure therapy for OCD is most effective when guided by a therapist and not done independently. It’s also more effective when using both in vivo and imaginal exposure, as opposed to solely in vivo.

Panic disorder

Interoceptive exposure therapy is often used to treat panic disorder. According to a 2018 research review of 72 studies, interoceptive exposure and face-to-face settings, meaning working with a trained professional, were associated with better rates of effectiveness, and people were more accepting of the treatment.

How My Dog Helped Me Understand My OCD

OCD is a hugely misunderstood mental condition.

Many people who can wrap their heads around anxiety disorders and clinical depression can’t do the same for OCD.

In part, this is because there’s so much misinformation about the condition, compounded with a great deal of misrepresentation in popular media.

Another reason is that OCD shows up in so many ways, and explaining “OCD logic” is difficult. Even people who have been diagnosed with OCD struggle to understand it.

This misunderstanding can be a problem.

Many people with OCD don’t quite realize what’s happening to them. This means that it can be more difficult for them to seek help. It can also be scary, as you don’t quite understand your thoughts or behavior. Also, many people with OCD are misdiagnosed, which means they might not get the treatment they need.

Personally, I’ve found that understanding my OCD has been the key to dealing with it.

OCD is made up of two parts:

  • obsessions, which are intrusive, unwanted, persistent thoughts
  • compulsions, which are actions you perform to “relieve” those thoughts

Sometimes, the compulsion is logical.

For example, the obsession might be the persistent thought that you’ll accidentally leave the house unlocked, and your compulsion might be to check the locks 10 times.

For some of us, the compulsions are meant to get rid of the thought. For others, it’s meant to reduce the chances of your fear actually occurring.

For those of us who think our obsessive thoughts will manifest our fears, it’s both.

In other situations, the compulsion seems totally unrelated.

I used to have intrusive thoughts that all my loved ones would suddenly all die. I had a compulsion where I’d wring my hands. Although these seem totally unrelated, it’s what made sense to some part of me at the time.

In that way, a compulsion is a lot like scratching an itch.

Even though you know scratching won’t make the rash go away, you want that temporary relief. There’s a part of you that believes your compulsion will “neutralize” or soothe the threat.

And sometimes, scratching makes a rash worse: it opens your skin, leading to further inflammation and redness.

In the same way, engaging in those compulsions doesn’t help your mental health. But at the time, it feels necessary.

When my dog itches, I don’t feel it — I only hear and see the scratching. And in the same way, people never see the obsessive thoughts that plague me daily. They see only the compulsions.

It’s easy for me to yell at my dog to stop scratching, but it doesn’t help. It’s also easy for people without OCD to advise those with germophobia to just stop cleaning things excessively, but that doesn’t help.

While it sounds simple in theory, it’s as hard as trying not to scratch after you’ve rolled through poison ivy.

And that’s why OCD is so misunderstood: Other people see only the tip of the iceberg.

Alec Baldwin Detailed His ‘Serious’ Struggle With Obsessive Compulsive Disorder

  • Alec Baldwin revealed he struggles with obsessive compulsive disorder (OCD).
  • He was recently diagnosed and has begun to track his symptoms.
  • He hopes to raise awareness by talking about it and giving it the platform it deserves.

    Alec Baldwin has been in the spotlight for decades. He’s produced films, starred in them, and made people laugh with comedy. But he’s never felt fully comfortable revealing a certain part of himself, until now. After years of contemplation, Baldwin has revealed that he struggles with obsessive compulsive disorder (OCD), in hopes to give the condition the attention it deserves.

    The actor shared his experience on his new podcast, What’s One More, which he hosts with his wife Hilaria Baldwin. They were joined by Howie Mandel, who told the public about his OCD in 2006, and his wife Terry Mandel.

    The Baldwins were delighted to talk to a couple who are familiar with how OCD can impact a family. “We’ve been learning a lot about OCD over the past few years,” Hilaria said, calling it a “very personal” issue. Then Alec began to open up.

    “OCD is something I personally struggle with,” he said. “I’m grateful to Howie for opening up at a time when few people were talking about this publicly, and there was even more of a stigma about OCD and mental health than there is today. It’s through empathy, understanding, and being kinder to one another that we can finally remove the stigma and change the narrative.”

    Alec didn’t explain his symptoms in depth but noted that he, like Howie, experiences a fear of germs and intrusive thoughts. He added that he’s just now beginning to track them.

    “Is germophobia the only way that that OCD was expressed, and what was the beginnings of when you started to track that and sense that?” he asked the America’s Got Talent judge. “Because I’m going through this myself now. I am, like really seriously.”

    OCD can be broken down into two major components, per the National Institute of Mental Health. First, there are obsessive thoughts, which can spur high anxiety. The second is compulsions, or urges to do rituals or practice certain behaviors to try and control these thoughts and anxieties.

    As Howie has previously explained, he said he experiences intrusive thoughts that others can easily brush off. For example, he often thinks he didn’t wash his hands well enough after touching something dirty, or worries that he didn’t lock the door after leaving his house.

    Up until now, Alec had only briefly spoken of his symptoms. In 2017, he described an episode to NPR that occurred on his way to catch a flight. “I walked out of that house with almost crippling OCD. I’d be standing in the hallway of my apartment in New York, and the driver was downstairs, and I needed to get into the car now, right now, or I was going to miss my flight, and I’d be making sure that all the books were stacked neatly on the table in the entry hall of my apartment,” he explained. “I’d be sitting there literally with my thumbs squeezing the books so all the seams were right and the books were stacked just so.”

    He attributes those feelings to growing up in a chaotic household with five siblings. “I didn’t realize it was all coming out of this house of mine, which was just a hurricane and a mess all the time, because my mother just didn’t have the energy to clean up after six kids,” he said.

    Now, at 63, he’s finally putting a name to it all while receiving great support from Hilaria. “We’re still very new to the journey of understanding what OCD is, but we’re learning that by being open about our challenges, we find a community where we realize we are not so alone, and we can be a part of paving the way for more people to seek help,” she said on the podcast.

    She continued her message on Instagram, showing gratitude for the Mandels and everyone willing to be vulnerable about their mental health journeys. “Grateful for you, Howie and Terry, for our conversation,” she wrote. “Your gift of sharing touches many and saves lives.”

Some OCD patients may experience a decrease in symptoms during the pandemic, new study finds

TORONTO —
Some people with obsessive compulsive disorder may actually experience improvement in symptoms during the pandemic, a small new study out of Belgium finds.

The study, published in Psychiatric Quarterly, looked at how symptoms in people with OCD before March 2020 compared to the start of the COVID-19 crisis, to determine how the pandemic impacted obsessive compulsive behaviours.

Researchers interviewed 49 OCD patients and 26 family members to assess OCD symptom severity, family accommodation, depressive symptoms, specific stress related to the pandemic and stress related to the “waxing and waning” pattern of the pandemic.

The study found that for most of the OCD patients interviewed, symptoms increased at the start of the pandemic and during the first lockdown in Belgium in March 2020, they improved as the pandemic progressed.

Researchers predicted that the slight improvement in OCD symptoms was the result of a number of factors, including feeling safer because other people were practising better hygiene, increased time spent alone and away from OCD triggers, and more free time to develop insight into compulsions and view them as less threatening or serious.

However, the study also found that patients who had increased family accommodation, which involves family members removing triggers, reassuring obsessive habits and taking over, showed increased levels of OCD symptoms.

Family accommodations are widely viewed by researchers as a factor in increasing OCD symptoms and preventing people with OCD from dealing with their behaviour.

Researchers predict that increased stress amongst family members, more time spent at home, and increasing feelings of responsibility towards family members with OCD, have all grown in response to the pandemic thus resulting in more family accommodation and worse OCD symptoms.

However, despite a decrease in OCD symptoms such as habitual actions, the study found that rates of depression, anxiety and stress amongst OCD patients increased across the board during the pandemic.

Other research has shown that despite original beliefs that OCD patients would experience significant increases in symptoms, some people haven’t experienced any changes in thier behaviour since the start of the pandemic.

One study found that while some​ people experienced worsened OCD symptoms during the pandemic, their triggers were not associated with contamination or fear of illness, rather stress and anxiety which often cause obsessive compulsive behaviours.

However, Dr. Evelyn Stewart, a Canadian psychiatrist and professor at the University of British Columbia, who wasn’t involved in the Belgium study, is worried that the improvement some OCD patients have experienced may offer false hope.

“The part that I am concerned about is that it might actually appear like OCD is improving for a number of individuals but that’s not actually true,” says Stewart in an interview with CTV News. “All of a sudden with COVID, it is totally valid and appropriate to be doing a lot of double checking, to be doing extra washing, to actually not go places or be in contact with people if you have concerns about the possibility of contamination, but as things go back to the new normal, whatever it’s going to be, it’s going to be really challenging for individuals with OCD who have contamination worries to go back to the pre-COVID norm and to be able to accept the little bit of risk that’s there.”

Similar to the study’s conclusions, Stewart says that improvement in OCD patients’ symptoms is likely the result of more time spent in isolation, feelings of validation towards washing and hygiene practices and feelings of relief that they no longer need to explain their behaviour.

Stewart says that OCD is focused on certainty and the ability to feel like you’ve done everything you can to keep yourself safe. With access to vaccines and lockdowns ending, Stewart says that feelings of uncertainty will occur and obsessive compulsive behaviours may return.

There is also concern, Stewart says, that OCD cases will increase after the pandemic is over, as the result of habitual washing practices and increased anxiety and fear towards illness and contamination.

Stewart’s lab has been conducting an ongoing study that has involved over 2,500 respondents and asks participants questions related to OCD tendencies and their implications. The study found that 15 to 17 per cent of respondents reported symptoms related to OCD.

In the general population, OCD typically appears at a rate of between one to two per cent of people.

“I suspect as we return whatever post-COVID life will be, there will be many news cases that will be identified,” says Stewart. “While there may have been some cases that improved during COVID, there may be new onset cases.”

Obsessive compulsive disorder convinced woman she was a ‘dangerous’ murderer

Obsessive compulsive disorder (OCD) is a widely misunderstood condition. It is treatable, but it can take years and thousands of dollars to access the right help in New Zealand. CECILE MEIER reports.

It all started with a thought. What if she killed her husband? Most of us have disturbing ideas – while holding a knife or walking past a cliff – and are able to dismiss them and move on. But that thought took Yvonne Tse down a spiral of obsession and crippling anxiety. The Auckland consultant stopped sleeping. She stopped using knives.

Her OCD made her so afraid she might harm someone that she stopped going to work. She locked herself inside her flat, suffocating in the cruel prison her fears had built. Within six weeks, her OCD had convinced her that she was a dangerous murderer, a psychopath, a sex offender. She wanted to die.

Auckland consultant Yvonne Tse lives with a form of obsessive compulsive disorder known as “Pure O”.

“I thought I was losing my mind. I always knew that I never wanted to act on any of my thoughts, but I was genuinely convinced I was dangerous, and it was better for society if I didn’t exist.”

People joke that they are “a bit OCD” because they like things to be tidy. We see it like a quirk about washing hands, flicking switches and counting. But for many who live with OCD, the compulsions are invisible and crippling. They are taboo thoughts looping in their heads. Endless what-ifs, mental checks, going over past events and seeking reassurance.

READ MORE:
* Aly Raisman opens up about her struggles with OCD for the first time
* Coronavirus: Health Minister David Clark criticised for telling people to be OCD about hygiene
* Amanda Seyfried speaks frankly about her 11-year struggle with OCD

GPs and even mental health professionals often fail to spot this form of OCD, known as “Pure O”. It can take years to get a diagnosis, and it is “virtually impossible” to access effective treatment for all forms of OCD through the public system due to a shortage of psychologists, NZ College of Clinical Psychologists executive advisor Dr Paul Skirrow says. Even those who can pay about $200 a week to go private struggle to find someone, with many psychologists closing their waiting lists to new clients, he says.

One or two people in 100 develop OCD, according to the Ministry of Health. It can affect anyone and usually starts in childhood. The exact cause of OCD is unknown.

OCD ‘a shape-shifting monster’

Yvonne Tse loves her husband very much. The thought that she could kill him popped into her head in August last year, as she was thinking of starting a family with him. Him dying was her biggest fear.

“OCD is a shape-shifting monster. It preys on whatever you fear the most,” she says.

Tse’s OCD brings relentless and frightening intrusive thoughts on a daily basis.

It was a stressful time, during Auckland’s second lockdown, with work tensions and unwell family members adding to Tse’s anxiety. The more she tried to get rid of the thought, the more it came, with other repugnant thoughts piling up on top of it.

She rang her GP four times over several weeks. She was prescribed anti-depressants and sleeping pills, which was not ideal as she felt suicidal, she says. She was told to book a private appointment with a psychiatrist at a cost of $500. There was a six-week wait.

Her thoughts became more and more oppressive and Tse shut herself in her flat, unable to sleep, work and talk to loved ones. She was referred to Auckland’s mental health crisis team. A psychiatrist gave her “a bunch of meds” and said she had anxiety characterised with obsessive thoughts.

The crisis team called her every day, but she was getting sicker and sicker. On the brink of suicide, she was sent to a respite clinic for a week. That’s where she finally got the right diagnosis. She was not going crazy; she had obsessive compulsive disorder.

“I work with prisoners and criminals,” the psychiatrist at the respite clinic told Tse. “You are not that. The thoughts are completely out of line with the values you hold as a person.” The psychiatrist promised her it was treatable.

Getting a diagnosis for “Pure O” is challenging, partly because people who live with OCD often have other mental health conditions, such as anxiety or depression, and partly because they are ashamed of their thoughts, Wellington clinical psychologist Ben Sedley says. Some might even worry that seeking help could land them in jail, or lead to their children being taken away.

“My OCD fixates on some of the most taboo topics known to man. I genuinely thought that I was going to get locked up for the rest of my life,” Tse says.

Tse is learning to live with OCD thanks to medication and therapy.

A social worker or health professional with no understanding of OCD might put someone disclosing distressing thoughts through stringent risk assessments, but there is no risk, Sedley says.

In his experience, people who live with OCD tend to be well-intentioned and conscientious people who are tortured by their worst fears. They constantly think of trying to protect others from harm.

There are no recorded cases of a person with OCD carrying out their obsession, research published in 2009 found. “The person is no more likely to act on their intrusions than a person with height phobia is to jump off a tall building. The obsession represents a type of fear … that the patient wishes to avert at all costs,” an article published in Advances in Psychiatric Treatment said.

Sedley, who co-authored Stuff that’s Loud: A Teen’s Guide to Unspiralling when OCD Gets Noisy, defines OCD as having a distressing and unwanted thought, feeling or image, and feeling compelled to do something to take away that feeling. The compulsion might be cleaning hands, ordering things, avoiding playgrounds, praying too hard, going over in your mind all the evidence that you are not a bad person, or saying things in your mind over and over again. It is not always apparent.

If their OCD plants a seed in someone’s head that they might be a paedophile, they might avoid children, or stop driving past schools, Sedley said.

“They constantly check their physiological reactions when they see a child on TV, they go through past events in their lives. It’s really distressing. It’s mortifyingly embarrassing. They know they would never harm a child, but they keep thinking: ‘What if I do? What if I did it in the past and don’t remember it?”

Clinical psychologist Ben Sedley says people who live with OCD tend to be well-intentioned and conscientious people tortured by their worst fears.

OCD is a loop in which anyone can get caught, he says. You don’t need to be traumatised to get OCD. There may be a small genetic link, but it’s not because you have someone in your family who lives with OCD that you will get it, he says.

Opening up her worst nightmares

The good news is that there is an “incredibly effective” treatment, called Exposure and Response Prevention therapy (ERP). The bad news is, it is “bloody hard to access” in this country, even for those who can afford to go private, Sedley says.

ERP, a form of cognitive behavioural therapy, involves exposing patients to their fear or obsession, and helping them chose not to do the compulsion. Instead, patients wait for the anxiety to decline as they get used to handling the fear. If someone is scared of germs, they might gradually make contact with dirty things. If someone is scared of being a murderer, they expose themselves to the scary scenarios via scripts with their therapist and at home.

“Instead of trying to get rid of the thought, let’s have it. If you watch a scary film 50 times, sometimes it is still scary, but you are realising that your brain can handle and manage it,” Sedley says.

Research shows ERP is effective for OCD, with a success rate of about 70 per cent. Sedley has helped countless people get back to living a normal life with it. More traditional forms of talk therapy are not helpful for people who live with OCD, and can even make it worse, he says.

When Tse opens up about her worst nightmares in the therapist’s office, or on her couch for her “homework”, her chest tightens, her stomach clenches and her throat closes.

“I almost hold my breath out of fear. It is fear that consumes me first, then comes the panic straight after. A bad day is me crying on the couch and trying to get through it. A good day I can get up and cook dinner afterwards and not worry.”

After several months of weekly sessions, she is able to handle her OCD and live a normal life.

But it took her months, thousands of dollars and a bit of luck to find a psychologist with experience in ERP. She wishes she had not had to want to die to find out about “Pure O” and ERP. She wishes GPs knew more about OCD, and that people would stop joking about it.

“It’s debilitating and not something to be joked about at all. It is not a joke. It is not.”

She knows she is lucky to have the money to pay for therapy and worries about those who don’t have the same financial privilege. This is one of the reasons she chose to talk openly about her OCD.

“If you recover loudly, people need not suffer silently,” she says.

Effective treatment out of reach

Jennifer Eve has not been so lucky. The Christchurch primary school teacher was diagnosed with contamination OCD six years ago after a suicide attempt at age 18, but was told she was not severe enough to qualify for specialist mental health services. She can’t afford to go private.

Contamination is the better-known form of OCD. People who live with it have an overwhelming feeling of distress when they come into contact with substances, objects, people or animals viewed as contaminants.

At first glance, Eve is a happy, articulate and energetic young woman. She laughs as she lists the many visible compulsions her OCD dictates, repeating frequently that she knows they don’t make any sense.

Christchurch primary school teacher Jennifer Eve has been battling OCD for seven years.

If she doesn’t wash her hands and clean surfaces three times in a row, she has a panic attack. She is the only one in her flat who can wash the dishes, with a four-brush system. If someone else does it, she washes the dishes again. She has three mugs that no-one else can ever touch, otherwise she will not be able to use them again.

She has two showers a day, using the same products in the same order. If she skips a step, she panics and has to start over again. She counts words in conversations, which need to end in multiples of eight. At the end of each work day, she spends an hour deep-cleaning the classroom. She will skip her beloved nephew’s third birthday party because it will be at a trampoline park, which means germs and feet out of shoes, and she knows she won’t cope.

Eve doesn’t complain much about the compulsions, even though they are clearly time-consuming, tiring and limiting. But she loses her happy composure when she describes the distressing thoughts that come with the compulsions. Tears fill her eyes. She struggles to find the right words.

Her OCD tells her on a loop that if she doesn’t complete her cleaning routines, she or someone she loves will get hurt, get cancer, or die in horrible circumstances. Every day, she tries to shut down OCD thoughts telling her to harm herself as a punishment for failing to complete tasks. She never acts on those thoughts.

Eve has learned to cope with her cleaning compulsions but would like help to understand her distressing thoughts.

“I absolutely don’t want to die. Suicide is not an option for me, but it’s like a voice in your head that doesn’t stop, really. It’s exhausting.”

Eve’s flatmates, friends, family and colleagues all know about her OCD. But she keeps the terrifying thoughts to herself.

After her diagnosis, Eve was prescribed medication and referred to brief intervention counselling. The primary care intervention gives people in mild to moderate mental health distress access to six free sessions with a counsellor. Just as she was starting to make a connection with the counsellor, the sessions ended. After that, Eve went five years without accessing therapy, thinking she could manage.

But at the end of last year, the intrusive thoughts intensified, and she became unwell. She was referred again for the six free counselling sessions, made a bit of progress, and it was over again.

She can’t afford to continue the sessions privately on a teacher’s wage. Medication helps, but her OCD is still debilitating.

Her job (teaching 5-year-olds is a lot, germ-wise), and her flatmates (who are not the tidiest people) are an exposure therapy of sorts. She has learned to let go of things she can’t control, which has been helpful, she says. But she needs to understand why she has disturbing thoughts, what they mean and how to combat them effectively. And she can’t do it alone, or within six counselling sessions.

Eve remains positive despite her challenges accessing treatment.

Despite the challenges, Eve remains positive. She has found support through a Facebook group for Kiwis living with OCD called Fixate. And just knowing effective treatment exists gives her hope, even if she can’t afford it for now.

A Ministry of Health spokesman says people with severe OCD do get referred for treatment by people trained in ERP, usually psychologists. It may also be provided by “other mental health professionals”, he says.

People with mild to moderate OCD can access immediate support in primary care at no cost, he says.

NZ College of Clinical Psychologists’ Paul Skirrow and OCD advocate Marion Maw beg to differ.

Because people living with OCD are not likely to harm themselves or others, they are usually unable to access specialist care, Skirrow says. Only the most severe cases get referrals, and even then they have to wait months to be seen.

This is because only about a third of the 1600 clinical psychologists in this country work for district health boards. Most work for Corrections and ACC, which pay much more, or in private practice.

Counsellors and the Government’s new 30-minute GP-based wellbeing service are unlikely to provide adequate treatment to people with complex mental health conditions such as OCD, he says.

GPs, mental health providers and advocates told Stuff earlier this month that overwhelmed specialist mental health services are limiting access to those who are actively suicidal.

Maw says people who live with OCD are commonly told they are not “severe enough” to get a specialist appointment, despite their real distress.

“My impression is that if you are managing to keep working or studying then that’s regarded as evidence that you’re ‘high-functioning’.”

OCD advocate Marion Maw is an admin for a private support group on Facebook.

The Government has dedicated funding to increase the number of psychologists getting trained, but it is going to take years to trickle down and is still far from enough, Skirrow says.

The Government has increased the number of funded psychology internships each year from 12 to 20, a ministry spokesman says. Professional psychology training takes at least six years.

Perinatal OCD

Sophie* was so afraid she would accidentally smother her first baby that she stopped breastfeeding her after six days. The Bay of Plenty finance professional was so scared she might somehow accidentally sexually abuse her that she avoided nappy changes and bathing her at all costs. Intrusive thoughts waxed and waned for several months, but she was still able to cope, she says.

“When there was no other option and I had to change a nappy, I felt fear flowing through my body. I did it and locked myself in the bathroom afterwards to have a panic attack.”

Perinatal OCD affects about 1 per cent of women in pregnancy and 3 per cent of women postnatally, studies suggest. New parents with pre-existing OCD may find that their symptoms intensify, or start experiencing OCD for the first time after having a child. Compulsions range from staying up all night to check a baby is still breathing to excessive cleaning, to trying to shut down unwanted thoughts of harming their child.

With her second child, Sophie was able to keep her OCD at bay and about two years without much anxiety flew by. But when her children were 2 and 4, she went through a stressful patch and one repugnant thought unravelled it all.

“I was walking through my garage and thought – what if I abuse my kids? From there it snowballed into: What if that time they went to the neighbours’ house, they were abused? What if the babysitter harmed them, what if, what if, what if?”

Postnatal OCD is not very well known.

The next day, Sophie was sitting on her bathroom floor, rocking and begging her husband not to go to work. She stopped eating and sleeping and lost 6kg in a fortnight.

Her compulsions included constant mental checks, praying, counting in her head and avoiding sharp objects and news stories.

“You read a story about a mum murdering her children, and then you just flip because how do you know you are not going to be that mum?

“You get stuck in this loop of trying to prove to yourself that you are not the thought that you are having. Everything seems like a warning sign, your body is in fight or flight constantly.”

Before going to her GP, Sophie rehearsed what she would say with her husband. How would she say she was afraid of harming her children without saying it? They were terrified the children could be taken away.

“I can only imagine how people who are already stigmatised as a minority would never seek help. If I am white, middle class and can afford therapy and I struggled, what hope can others afford?”

The GP told her it was generalised anxiety disorder and gave her a pamphlet about mindfulness. She went back three times but “they didn’t get it”, she said.

Eventually, she self-diagnosed with ‘doctor Google’.

“When OCD came up, I was like: ‘What? But I am not pedantically tidy’. I went back to my GP, and she said: ‘No you don’t have OCD because you don’t flick light switches.”

The GP gave her anti-depressants and told her there would be a three-month wait to see a specialist, before reminding her about mindfulness.

“I went private because I knew that if I didn’t get help within a matter of days, I wasn’t sure I would see through to the end of the week.”

That was four years ago. She had therapy twice a week at first, at a cost of about $200 a session.

Reading through the scripts detailing her most excruciating fears made her vomit and shake.

“I couldn’t have done it without someone helping me through it.”

A year of weekly sessions each costing $450 has allowed Sophie* to live a normal life again.

After six months, she was able to function again. She then sought more specialised treatment in the United States via Skype and had weekly sessions for a year, at $450 a pop.

Within a year, she was living a normal life again.

“All we hear is talk, talk, talk about mental health. But if we don’t have enough psychologists in New Zealand, why are we not using experts from around the world?

Even if the mental health system is overloaded, simply knowing that you have OCD can be enormously helpful, Maw says. She would like to see more basic training for frontline health workers, midwives and school counsellors around OCD so they are able to recognise the possibility, so it can be further investigated.

*Not her real name.

More info on OCD:

http://www.ocd.org.nz/

iocdf.org

Obsessive Compulsive Disorder

Where to get help:

1737, Need to talk? Free call or text 1737 any time for support from a trained counsellor

Lifeline – 0800 543 354 or (09) 5222 999 within Auckland

Youthline – 0800 376 633, free text 234 or email talk@youthline.co.nz or online chat

Samaritans – 0800 726 666

Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)

What’s Up – 0800 942 8787 (for 5–18 year olds). Phone counselling is available Monday to Friday, midday–11pm and weekends, 3pm–11pm. Online chat is available 7pm–10pm daily.

Kidsline – 0800 54 37 54 (0800 kidsline) for young people up to 18 years of age. Open 24/7.

thelowdown.co.nz – or email team@thelowdown.co.nz or free text 5626

Anxiety New Zealand – 0800 ANXIETY (0800 269 4389)

Rural Support Trust – 0800 787 254 (0800 RURAL HELP)

Supporting Families in Mental Illness – 0800 732 825

From panic attacks to obsessive compulsive disorders, how COVID-19 has taken a toll on mental health

At the start of the pandemic in 2020, the National Institute of Mental Health and Neurosciences, Bengaluru, started a national helpline for COVID-related mental health issues. The nature of calls in the second wave is different from those in the first. From psycho-social issues in the first wave, callers are now trying to cope with hospitalisation, death, grief and the like.

Dr K Sekar heads the Centre for Psychosocial Support in Disaster Management, which runs the helpline (080-4611 0007). He reveals that calls had plateaued by March, but are peaking again. “When we started the helpline in March 2020, we got 1-2 lakh calls within the first month itself. The issue then was, how to adjust. During lockdowns, there were calls about lack of rations and jobs, migrants unable to go home, general depression, etc. …that is, the calls were more about social situations.”

Now, in the second wave, it is more about the loss of loved ones, not being able to perform their final rites, the helplessness of not finding oxygen or beds, about the elderly left back alone, etc. “There are more calls on mental health issues and severe psychosocial issues now,” he says.

An example is of an 87-year-old man who survived COVID-19 but lost his wife to it. He didn’t wish to live anymore.

“Apart from talking to him about the meaning of life, etc, we also arranged for a person who would visit him frequently. Now he awaits that person’s visits,” says Dr Sekar. The helpline is currently following up with around 58,000 such patients.

During such calamities, a large section of people would have abnormal reactions, Dr Sekar said. Eventually, however, only about 10 percent of the population would need long-term care by mental health professionals. “Initially, about 90 percent of the population would have abnormal psychosocial reactions as we saw in the first wave; thoughts like, ‘Who is the government to ask me to sit at home?’, ‘Why can’t I go to work?’, etc. Now it’s coming down to about 60 percent of the population who have mental health issues but can’t be diagnosed as having a mental illness per se,” he says.

“Within about a year, the affected population will come down to 30 percent, that is, people suffering prolonged grief over the severe trauma they suffered. In another year, there would be about 10 percent who need long-term mental healthcare. This timeline can vary depending on the intensity of the situation.”

Based on evolving evidence from COVID-19 as well as previous experience from SARS and MERS epidemics, this February, the Psychiatry Department at NIMHANS published a document on the possible mental health effects of COVID. The document says a mental health pandemic is looming and that our systems need to be prepared for this. Following are some key pointers from the document.

How COVID-19 has lead to widespread anxiety

The document says that, in the current scenario of COVID-19 deaths, lockdowns, job losses, etc, anxiety and depression are quite widespread. In most cases, anxiety may not interfere with daily functioning or would disappear once the stressor is gone. In some other cases though, the mental health problem could interfere with daily life, or cause suicidal thoughts, to the extent that the patient would need treatment by a mental health professional immediately.

Several types of anxiety disorders are expected to increase with COVID-19 . Cases of Generalised Anxiety Disorder (GAD, wherein the person suffers persistent nervousness, irritability, poor concentration, sleep disturbances, etc), panic disorders (characterised by panic attacks), phobia such as excessive fear of crowds, are expected to appear.

Cases of Obsessive-Compulsive Disorder (OCD) are expected to increase with COVID-19 , with distressing obsessions about contamination, and washing rituals that can last hours. Healthcare workers are more vulnerable to this in the current scenario.

Cases of Post Traumatic Stress Disorder (PTSD) are also expected to arise due to COVID-19 . The NIMHANS document cites a study that found a seven-nine percent prevalence of PTSD among those living in areas hit hard by COVID-19 .

The document points out that worldwide, increased suicide rates are also being reported during COVID-19 . Severe COVID-19 infection, losing family members, losing jobs and livelihood, having a mental illness, are among the risk factors for suicide. Substance use (mostly tobacco and alcohol) to deal with isolation and stress is also expected.

During COVID-19 , besides recognised mental health conditions, many new factors have emerged as ‘life events’ – that is, social experiences that have an impact on the individual’s mental health. These include COVID-19 diagnosis for oneself or family members, lockdown, migration, work-from-home, online education, etc, which have never been on any rating scale. These factors should be considered, says the document.

“Normally we may have 2-3 life events a year; for example, having fever for a week and recovering. But now, people are going through multiple life events in a short period. Also, their family, society, community are all being challenged at the same time,” says Dr Sekar.

Effects on COVID-19 patients

COVID-19 infection itself can affect the brain and lead to neurological effects like agitation and delirium, but severe dysfunctions are rare, says the document. COVID-19 ’s neurological effects are not completely clear yet. However, psychological effects are more common, due to traumatic memories of suffering from COVID-19 , isolation and stigma, etc. High rates of anxiety, depression and stress-related disorders are being reported from those who recovered from acute COVID-19 infection.

This is similar to what was reported during MERS and SARS outbreaks, with survivors having symptoms even a year after recovery. In the case of SARS, nearly half the survivors had PTSD symptoms, says the NIMHANS document. (However, SARS and MERS had much higher death rates compared to COVID-19 , hence the effects can’t be directly generalised). Brain fog – a state of reduced cognitive functioning – is also being increasingly recognised among COVID-19 survivors.

Mental health of some is more affected

While almost everyone is facing mental health effects of COVID, some already vulnerable groups are even more affected. These include:

Children and adolescents: According to various studies, lockdown restrictions are causing some children to be attention-seeking and have higher dependency on parents. Additions like gaming behaviour, uncertainty about the future due to exam postponement, etc are seen in teenagers.

The NIMHANS document quotes a study from China among 2,330 children, which found that around 22 percent reported depressive symptoms and 19 percent reported anxiety symptoms during COVID. Another study from China among over 8000 adolescents cited the prevalence as 43 percent and 37 percent respectively.

An Indian study which specifically focused on children in isolation/quarantine found that 30 percent of them met the criteria for PTSD. Children who lose their parents have a higher risk of developing mood disorders, psychosis, death by suicide in adulthood, says the NIMHANS report. Also, children with physical or mental disabilities are more affected during COVID since services to them have been almost cut off.

Elderly at higher risk: Awareness about higher COVID risk, further social isolation, difficulty accessing essential services, all increase the elderly’s risk of mental health issues. They may commonly face sleeplessness, feelings of emptiness and imprisonment, health anxieties, etc. And some may go on to develop disorders like depression, anxiety disorders, substance use and PTSD. Those living alone or in old age homes are more vulnerable.

People with pre-existing mental issues: In most parts of the world, COVID has led to worsening or relapse of pre-existing mental health conditions. People with disabilities may have fears about financial security, access to healthcare and provisions, about their caregiver falling sick, etc. Surveys show this group has been disproportionately affected by COVID in these aspects.

Frontline healthcare workers: A study in Karnataka found that 26.6% of frontline health workers suffered from anxiety disorders, and 23.8% suffered depression. Certain categories including nurses, those working in ICU, less experienced health workers, those with poor job security, were found to be more vulnerable. Anxiety related to COVID infection, sleep disturbances, burn-out, suicidal thoughts, etc may be present. While the majority would recover over time, some will need immediate psychiatric intervention, the report says.

People in quarantine/isolation: People under home quarantine may be affected by the fear of infection, depression, loneliness, stigma, loss of pay, etc. Studies show that those in hospital quarantine/isolation had more anxiety and depressive symptoms. In vulnerable people, hospital quarantine can lead to acute stress, and they have a higher risk of PTSD later.

Mental health support systems needed

Dr Pratima Murthy, who heads the Psychiatry Department at NIMHANS, says, “In addition to mental health impacts during the pandemic, it’s well-recognised that after the pandemic also, there will be ongoing stress for a lot of people. Also, the health difficulties because of ‘long COVID’ can create psychiatric issues like anxiety and depression. And we do expect other neuropsychiatric complications from COVID infection itself.” Hence, she says, proper support systems should be built in to help people recover quickly and get back to their lives.

This article was first published in Citizen Matters, a civic media website and is republished here with permission. (c) Oorvani Foundation/Open Media Initiative.