tag:theconversation.com,2011:/au/topics/ocd-3624/articlesOCD – The Conversation2024-02-29T13:17:23Ztag:theconversation.com,2011:article/2246592024-02-29T13:17:23Z2024-02-29T13:17:23ZSkin picking is often trivialised as a bad habit – but dermatillomania can be dangerous<figure><img src="https://images.theconversation.com/files/578675/original/file-20240228-24-6y8te7.jpg?ixlib=rb-1.1.0&rect=33%2C16%2C5573%2C3715&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-squeezing-pimple-looking-on-284422616">Tom Wang/Shutterstock</a></span></figcaption></figure><p>Our skin is often covered with tiny imperfections – blemishes, moles, cuts and spots that we’re all guilty of picking at from time to time. Consider the temptation of that bulbous yellow head of a spot ready to erupt, or peeling back a scab that’s been there for days to find the newly healed skin beneath. </p>
<p>But for some, skin picking is not an occasional guilty pleasure, but an obsessive condition known as excoriation disorder. Or to give it a medical name, <a href="https://www.ocduk.org/related-disorders/skin-picking/">dermatillomania</a>.
It is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7115927/">relatively common in the general population</a>. Self inflicted skin disorders, of which dermatillomania is one example, account for around <a href="https://pubmed.ncbi.nlm.nih.gov/31178108/">2% of clinical appointments</a> in dermatology. </p>
<p>Dermatillomania is more than just finding satisfaction in popping a volcanic spot. It is a disorder that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731172/">can have serious</a> and even fatal consequences. It is characterised by consistent picking at the skin, which becomes a habit, much as nail biting or thumb sucking does. This may focus upon the different pigmented spots that are visible (such as moles or freckles), in an attempt to reduce their appearance or dig them from the skin. </p>
<p>If the patient also has an associated dermatological disorder <a href="https://eczemacompany.com/blogs/blog/managing-dementia-skin-picking-disorder">such as eczema</a>, psoriasis <a href="https://www.aocd.org/page/AcneExcoriee">or acne</a> which causes lesions to develop, this may exacerbate a heightened desire to eliminate the rash from the skin.</p>
<p>But the patient may also attack unblemished skin, either with the nails or using sharp objects as tools, like needles or tweezers to gouge and scrape at perceived imperfection. Some may also go as far to <a href="https://pubmed.ncbi.nlm.nih.gov/35350511/">bite at the skin</a> with their teeth. The skin picking may persist for long periods of the day, becoming an unconscious habit. In some cases, it may even extend into sleeping hours.</p>
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<p>The disorder creates progressive skin damage. Normally after sustaining a cut or injury, the area of tissue becomes flooded with restorative cells. This includes white blood cells and fibroblasts which fight infection and weave the ends of a wound back together. Constant picking of a wound disrupts the matrix and web that these cells work around, like builders on a set of scaffolding. This interferes with the normal healing processes, and <a href="https://www.medicalnewstoday.com/articles/picking-scabs">can result in permanent scarring</a>. To complicate matters further, wounds that stay open can also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337191/">introduce infection</a> into the skin and deeper tissues. </p>
<h2>Related disorders</h2>
<p>There are other related disorders that have a close association with dermatillomania. Hair and nails are both extensions of the skin, and the similarly named condition trichotillomania (often shortened to trich) is another example. </p>
<p>This is where the patient persistently plucks or pulls at their hairs. Like skin picking, patients with trich may describe intense relief or satisfaction in plucking, and may become agitated in the periods when they leave their hair alone.</p>
<p>Hair plucking isn’t limited to the scalp – the lashes, eyebrows and pubic regions may also be targeted. Some may also proceed to eat the hair – a condition called <a href="https://pubmed.ncbi.nlm.nih.gov/30099694/">tricophagia</a>. This is a subtype of the <a href="https://www.ncbi.nlm.nih.gov/books/NBK532242/">eating disorder pica</a>, where there is a craving for inorganic substances, or those with no nutritional value.</p>
<p>What causes the problem in the first place? There are many triggers for dermatillomania, which a doctor will try to establish in order to help. Often treating the condition involves exploring and addressing any obvious cues to start picking. Sometimes it may be as simple as being bored, or lack of engagement in a daily routine. In other cases, an association is found with mental health disorders, like anxiety or depression.</p>
<p>Dermatillomania shares many traits with <a href="https://pubmed.ncbi.nlm.nih.gov/33008538/">obsessive-compulsive disorder</a> (OCD), a two-fold condition. OCD patients become afflicted with persistent intrusive thoughts (obsessions) which compel them to carry out actions which help them alleviate the associated unpleasantness (compulsions). A common example is frequent hand washing to relieve the stress that comes from obsessive thoughts about coming into contact with germs via touch. Jack Nicholson won an Oscar for his portrayal of Melvin Udall in the 1997 film <a href="https://mghocd.org/as-good-as-it-gets/">As Good as It Gets</a>, a character who exhibits many of these traits.</p>
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<h2>How to manage the compulsion to pick</h2>
<p>There are several techniques that a skin picking patient can do to manage these urges themselves. Part of tackling habits is to provide a form of distraction. This might be using hand-held devices such a stress ball or fidget toy, to detract attention. Patients can also use simple strategies to making picking and plucking more difficult, such as wearing gloves or hats as barriers.</p>
<p>In more severe cases, clinical intervention may be required as treatment. <a href="https://pubmed.ncbi.nlm.nih.gov/28761349/">Medical treatment</a> for either existing skin or mental health conditions acting as a trigger may help, as may <a href="https://pubmed.ncbi.nlm.nih.gov/33654612/">cognitive-behavioural therapy</a> (CBT). This seeks to disconnect negative thoughts and behaviours which drive poor mental health, and make a more positive change.</p>
<p>It goes to show therefore that, for some people, the quest for dermatological perfection is more than skin deep. Our minds and skin share close physical and psychological bonds and while the habitual picking of dermatillomania might seek to iron out imperfections in skin, it could also be counter intuitive. And become a deeply ingrained obsession.</p><img src="https://counter.theconversation.com/content/224659/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dan Baumgardt does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Skin picking shouldn’t be dismissed as merely a bad habit. It’s a disorder that can have serious –even fatal – consequences.Dan Baumgardt, Senior Lecturer, School of Physiology, Pharmacology and Neuroscience, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2217262024-02-06T19:08:09Z2024-02-06T19:08:09ZWhy Heartstopper is Gen Z’s defining publishing phenomenon<p>When Volume 5 of Heartstopper, Alice Oseman’s graphic novel series (turned Netflix adaptation, turned cultural juggernaut) was published in December last year, the book was declared an <a href="https://www.hachette.com.au/alice-oseman/heartstopper-volume-5-instant-number-one-bestseller-the-graphic-novel-series-now-on-netflix">instant number-one bestseller</a>. In Australia alone, it sold 12,300 copies <a href="https://www.booksandpublishing.com.au/articles/2023/12/15/244785/heartstopper-the-secret-top-christmas-charts-in-aus-aotearoa-nz/">in its first week</a>.</p>
<p>To every generation a publishing phenomenon is born – and for Generation Z, it’s Heartstopper, which Oseman started writing aged 22 (she’s still just 29).</p>
<p>The rise of Heartstopper reads like a history of the last ten years in publishing tools and platforms. Oseman started self-publishing the comics on microblogging site <a href="https://aliceoseman.tumblr.com/">Tumblr</a> and webtoon platform <a href="https://tapas.io/aliceoseman">Tapas</a> in 2016, building up a loyal following and clocking millions of views. </p>
<p>Crowdfunding for the first print run <a href="https://www.thebookseller.com/news/oseman-crowdfunds-lgbt-comic-two-hours-816316">met the funding goal within two hours</a>. Hachette Children’s Group picked up <a href="https://www.thebookseller.com/rights/hcg-publish-oseman-s-online-graphic-novel-869686">world rights</a> for the series, publishing Volume One in 2019. </p>
<p>To date, five graphic novels, two novellas, a yearbook and a colouring book have been <a href="https://aliceoseman.com/heartstopper/graphic-novels/">published</a>. The graphic novels have also been adapted into a <a href="https://www.rottentomatoes.com/tv/heartstopper/s01">successful Netflix series</a>, with scripts written by Oseman herself. </p>
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<a href="https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/573605/original/file-20240205-27-dkiq4v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Heartstopper author Alice Oseman has written the scripts for the Netflix series.</span>
<span class="attribution"><span class="source">Marcus Laing/Netflix</span></span>
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<p>Heartstopper follows the sweet friends-to-lovers arc of Charlie and Nick, whom we first meet in Year 10 and Year 11. It depicts the giddying highs and dizzying lows of being young, queer and in love. </p>
<p>Through Charlie, Nick and other well-drawn characters, Alice Oseman beautifully portrays the inner workings of a healthy relationship, modelling open communication, help-seeking, allyship and active consent. The books also touch on rarely discussed topics like male eating disorders.</p>
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Read more:
<a href="https://theconversation.com/big-beautiful-females-and-familiar-dystopias-new-graphic-nonfiction-interrogates-21st-century-life-182224">Big beautiful females and familiar dystopias: new graphic nonfiction interrogates 21st-century life</a>
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<h2>Queer joy</h2>
<p>Queer joy is <a href="https://www.oxfam.org/en/queer-joy">defined by Oxfam</a> as a positive feeling we get from encountering signs of progress in gender equality and gender diversity. In the Heartstopper series, the narrative engine runs on themes of love, identity, first times, self-discovery, friendship and allyship. </p>
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<p>When we meet Charlie in Volume 1, he’s been out at his school as gay for a while. He mentions past bullying and there are moments of homophobia, but largely Charlie is accepted at school. Charlie’s friend Elle has transitioned their gender and has been enrolled into the girls’ school across the road. There’s never any suggestion this has been met with resistance or nastiness.</p>
<p>Of course, not everything comes easily to Charlie and Nick. The shadow side of the themes of love, connection and community includes <a href="https://theconversation.com/treating-a-childs-mental-illness-sometimes-means-getting-the-whole-family-involved-169729">mental ill-health</a>, body dysmorphia, <a href="https://theconversation.com/more-than-half-of-australians-will-experience-trauma-most-before-they-turn-17-we-need-to-talk-about-it-159801">trauma</a>, family conflict and <a href="https://theconversation.com/5-questions-your-childs-school-should-be-able-to-answer-about-bullying-222255">bullying</a>. </p>
<p>Nick’s brother, David, takes every opportunity to shame Nick for being gay, while Nick’s father is an absent parent. Meanwhile, trauma from Charlie’s past, including bullying and his <a href="https://theconversation.com/toxic-masculinity-what-does-it-mean-where-did-it-come-from-and-is-the-term-useful-or-harmful-189298">toxic</a>, closeted ex Ben’s coercive behaviour, has had some heavy impacts. </p>
<p>Charlie confesses to Nick that he used to <a href="https://theconversation.com/australian-teens-doing-well-but-some-still-at-high-risk-of-suicide-and-self-harm-83303">self-harm</a>, and Nick observes some worrying behaviour in Charlie in terms of food avoidance and anxiety. Nick talks to his mother who tells him, “Love can’t cure a mental illness”, and gives some practical advice: listen, talk, ask him what he needs, stand by him, but don’t try to take it on by yourself. </p>
<p>Nick encourages Charlie to seek help. After some reluctance, Charlie talks to his parents. He is diagnosed with <a href="https://theconversation.com/obsessive-compulsive-disorder-is-more-common-than-you-think-but-it-can-take-9-years-for-an-ocd-diagnosis-196651">obsessive compulsive disorder (OCD)</a> and anorexia and is admitted to a residential treatment program. As <a href="https://theconversation.com/a-male-character-on-heartstopper-has-an-eating-disorder-thats-more-common-than-you-might-think-211912">assistant professor of psychology Vivienne Lewis has noted</a>, eating disorders in boys and men are underrepresented in media and little understood in the community, so Alice Oseman is breaking important ground here.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/heartstopper-depicts-queer-joy-heres-why-that-can-bring-about-complicated-feelings-for-those-in-the-lgbtiq-community-183729">Heartstopper depicts queer joy - here's why that can bring about complicated feelings for those in the LGBTIQ community</a>
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<h2>‘Felt gaps’: the magic of comics</h2>
<p>Comics have a tumultuous history, especially for children. In 1953, in his book <a href="https://archive.org/details/fredricwerthamseductionoftheinnocent19542ndprinting">Seduction of the Innocent</a>, Frederic Wertham argued comics inhibit literacy, and called them “death on reading”. But the opposite seems to be true. </p>
<p>Comics and graphic novels are, for some kids at least, the gateway to a passion for books. For already engaged readers, it’s a way to diversify their reading and develop their visual literacy. English teacher <a href="https://search.informit.org/doi/10.3316/informit.039375598684308">Matt McCabe</a> points out that while comics can be read and understood comparatively quickly, they can be “studied multiple times from different angles”, making them suited to readers of all abilities. </p>
<p>Reading comics calls on a heightened awareness of the senses to make sense of the unfolding world within. Some of the magic of comics occurs in the gutter: the space between panels. The comics medium is also known for its disjuncture of word and image. These “felt gaps” prompt the reader to harness their imagination and life experience. </p>
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<span class="caption">The space between panels in comics prompts the reader to harness their imagination and life experience.</span>
<span class="attribution"><span class="source">Hachette Australia</span></span>
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<p>Because comics can show and tell two things at once, they are particularly good at representing the way identities are formed in relation to society and culture. There’s a scene in Volume 1 where Nick turns to Google to ask, “Am I gay?” Google searches like these have become a rite of passage for young Gen Zs, <a href="https://youthsense.com.au/youth-insights/why-australian-gen-z-lgbtqia-numbers-are-skyrocketing/">who are much more likely than older generations to identify as queer</a>. </p>
<p>An examination of Google trends from 2004 to 2023 highlights a steep rise in queries about sexuality, with <a href="https://www.culturalcurrents.institute/insights/lgbtq-identity">such searches surging over 1,300%</a>. Alice Oseman uses jagged panels and fragmentation to show Nick’s worldview exploding as he comes to terms with this new information about himself, in the fractured environment of a Google search response page.</p>
<h2>Heartstopper Volume 5</h2>
<p>By Heartstopper Volume 5, Nick is out to family and friends and Charlie is home and in therapy, but generally well. Charlie and Nick are in an established relationship, thinking about taking things to the next level. </p>
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<p>They are surrounded by a supportive and diverse group of friends, including a trans girl, another gay boy who is not interested in coming out, Charlie’s asexual sister, and a lesbian couple, reflecting a spectrum of LGBTQ+ experiences many kids would encounter in their own social milieu. </p>
<p>There is a subplot of two male teachers falling in love. One of these teachers encourages Charlie to consider running for Head Boy. (We’ll have to read Volume 6 to find out if he’s successful!) </p>
<p>Heartstopper Volume 5 focuses a lot on Nick who, as a final-year student, needs to make a decision about university. Initially he assumes he’ll go to the closest one, to stay near Charlie. Two friends, also facing this decision, accompany Nick on a road trip to visit campuses elsewhere, and gently encourage him to explore other options. </p>
<p>Alice Oseman handles with delicacy the fact that as high-school sweethearts, their paths may take them in different directions – and that only through supporting each other to grow will they both thrive. </p>
<p>Another important plot point involves discussions about sexual readiness, with both boys talking to each other and their friends about recognising when you might be ready for sex. The conversations demonstrate nuances of active consent and communication, and stand in stark contrast to Ben’s entitlement and aggression in Volume 1. A conversation in class shows not all young people are ready for sex –and that’s normalised too.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/big-w-has-withdrawn-welcome-to-sex-from-its-stores-to-protect-staff-but-teen-sex-education-can-keep-young-people-safe-209979">Big W has withdrawn Welcome to Sex from its stores to protect staff – but teen sex education can keep young people safe</a>
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<h2>Normalising queer love</h2>
<p>In Heartstopper, the representations of mental illness, trans identities and queer love are destigmatising and normalising. Charlie’s queer and quirky friendship group reminds me of the young people who trail in and out of my house on a regular basis. (My oldest daughter ran the queer club at her school, my middle child is non-binary.) </p>
<p>The depiction of Charlie’s OCD and anorexia as a result of past trauma is carefully optimistic, showing a fairly linear pathway from help-seeking to effective treatment. Oseman acknowledges, through Nick, that isn’t always the case: </p>
<blockquote>
<p>Staying in a hospital was a big risk. It probably isn’t helpful for everyone. But it was for him. He could actually focus on his mental health without worrying about school and what everyone thought.</p>
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<p>Oseman uses the comic form to alleviate the intensity, avoiding details about self-harm and restrictive eating, and never showing anything graphic. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/573386/original/file-20240205-19-omrnv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The representations of queer love in Heartstopper are destigmatising and normalising.</span>
</figcaption>
</figure>
<p>The message when it comes to mental health is that it takes a village to treat mental illness (siblings, parents, friends, clinicians, teachers).</p>
<p>Some readers, especially those of us who grew up in earlier decades, might feel sad or angry when they compare their school experiences to what’s shown in Heartstopper. Some who experienced the bullying but not the friendships in high school may struggle to believe kids can be this kind to each other. </p>
<p>For me, though, this is the queer joy of reading Heartstopper. In its focus on the love and community that surrounds Charlie and Nick, the Heartstopper graphic novels create a space for the reader, who becomes an intimate confidante – another member of Charlie and Nick’s tight-knit friendship group.</p><img src="https://counter.theconversation.com/content/221726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Penni Russon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Heartstopper is a celebration of ‘queer joy’ that uses the imaginative intimacy of graphic novels to invite the reader into its tight-knit world.Penni Russon, Senior Lecturer, School of Communication, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2192812023-12-07T17:28:07Z2023-12-07T17:28:07ZOCD is so much more than handwashing or tidying. As a historian with the disorder, here’s what I’ve learned<figure><img src="https://images.theconversation.com/files/563995/original/file-20231206-25-yjbxqt.jpg?ixlib=rb-1.1.0&rect=15%2C22%2C5077%2C3328&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/woman-touching-her-temples-hands-suffering-2196452389">Elena Abrazhevich/Shutterstock</a></span></figcaption></figure><p><em>Readers are advised that this article contains explicit discussion of suicide and suicidal and obsessional thoughts. If you are in need of support, contact details are included at the end of the article.</em> </p>
<hr>
<p>At the age of 12, “out of nowhere”, Matt says he started having repetitive thoughts concerning whether he wanted to end his life. Every time he saw a knife, he would ask himself: “Am I going to stab myself?” Or, when he was near a ledge: “Am I going to jump?”</p>
<p>Matt had heard a lot about teenage depression, and thought this must be what was going on. But it was confusing, he says: “I didn’t feel suicidal, I really enjoyed my life. I just had an intense fear of doing something to hurt myself.”</p>
<p>Shortly afterwards, pre-empted by hearing about a notorious banned film, Matt began questioning whether he, like the central character, might be a serial killer. These thoughts “kept coming and coming” and he would lie in bed running over scenarios, trying to work out whether he was “going crazy”:</p>
<blockquote>
<p>I really needed help. I didn’t know who to talk to. But it wasn’t on my radar to think about this as OCD.</p>
</blockquote>
<p>Obsessive-compulsive disorder (OCD) is a significant mental health diagnosis in the 21st century. The World Health Organization (WHO) lists it as <a href="https://www.bmj.com/content/348/bmj.g2183.long">one of the ten most disabling illnesses</a> in terms of loss of earning and reduced quality of life, and OCD is frequently cited as the fourth most common mental disorder globally after depression, substance abuse and <a href="https://www.nhs.uk/mental-health/conditions/social-anxiety/#:%7E:text=Social%20anxiety%20disorder%2C%20also%20called,better%20as%20they%20get%20older.">social phobia</a> (anxiety about social interactions).</p>
<p>Yet everything Matt knew about OCD, he tells me, came from daytime talkshows where “people were washing their hands 1,000 times a day – it was all about external and really extreme behaviours”. And that didn’t feel like what he was going through.</p>
<hr>
<p><em>Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. <a href="https://theconversation.com/uk/topics/tackling-the-mental-health-crisis-147216?utm_source=TCUK&utm_medium=ArticleTop&utm_campaign=MentalHealthSeries">In this series</a>, we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.</em></p>
<hr>
<p>A similar experience is recounted in the 2011 book <a href="https://overcoming.co.uk/582/Taking-Control-Of-OCD---VealeWillson">Taking Control of OCD</a> by John (not his real name) who, after a colleague had taken their own life, became “inundated with thoughts” about what he might do to himself. Every time he crossed the road, John thought: “What would happen if I stopped moving and was run over by a bus?” He also had thoughts of murdering those he loved. John recalled:</p>
<blockquote>
<p>Try as I might, I just couldn’t chase the thoughts out of my head … When I tried to explain what was going on to my girlfriend, I couldn’t find a way of articulating what was happening to me … At the time, I thought OCD was all about triple-checking you had locked the front door and that your drawers were tidy.</p>
</blockquote>
<p>Despite the prevalence of OCD in contemporary society, the experiences of Matt and John reflect two important features of this disorder. First, that the stereotype of OCD is one of washing and checking behaviours – the <a href="https://www.nhs.uk/mental-health/conditions/obsessive-compulsive-disorder-ocd/overview/">compulsions</a> aspect, defined clinically as “repetitive behaviours that a person feels driven to perform”. And that obsessions – defined as “<a href="https://www.nhs.uk/mental-health/conditions/obsessive-compulsive-disorder-ocd/overview/">unwanted, unpleasant thoughts</a>” often of a harmful, sexual or blasphemous nature – are viewed as obscure, confusing and unrecognisable as OCD.</p>
<p>People who experience obsessional thoughts are therefore frequently unable to identify their symptoms as OCD – and <a href="https://pubmed.ncbi.nlm.nih.gov/26132683/">neither</a>, very often, are the experts they see in clinical settings. Due to mischaracterisations of the disorder, OCD sufferers with non-typical, less visible presentations usually <a href="https://www.sciencedirect.com/science/article/pii/S2666915321001578?via%3Dihub">go undiagnosed for ten or more years</a>.</p>
<p>When John visited his GP, he was diagnosed with depression. He recalled that the GP concentrated more on the visible effects of his distress - a lack of appetite and disrupted sleeping patterns. The thoughts remained invisible. As he put it:</p>
<blockquote>
<p>I don’t know how you’re supposed to tell someone you don’t know that you have thoughts about killing people you love.</p>
</blockquote>
<p>Even for those with “textbook” OCD such as my friend Abby, “the compulsion is just the tip of the iceberg”. Abby was able to self-diagnose at the age of 12, when she experienced handwashing and locking door compulsions. She says people still think of her as “Abby [who] likes to wash her hands a lot”.</p>
<p>Now, she tells me, “I realise that I have no interest in washing my hands – I’m a pretty messy person, and I don’t mind other people being messy.” Rather than a love of cleaning, her acts were related to the altogether scarier obsessional thought: “What if I am going to hurt other people?”</p>
<p>Clinical guidelines, such as those provided in the UK by the <a href="https://www.nice.org.uk/guidance/cg31/resources/obsessivecompulsive-disorder-and-body-dysmorphic-disorder-treatment-pdf-975381519301">National Institute for Health and Care Excellence</a>, define OCD as being characterised by both compulsions <em>and</em> obsessions. So, why do the difficulties encountered by Matt, John and Abby – of recognising the internal thoughts that dominate their lives – appear to be <a href="https://letsqueerthingsup.com/2018/05/12/i-didnt-know-i-had-ocd-heres-why-the-stereotypes-are-so-harmful/">so common</a>?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Wordcloud for obsessive-compulsive disorder (OCD)" src="https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564001/original/file-20231206-27-hklxdx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">OCD is a multifaceted disorder, yet understanding tends to focus on the visual, compulsive aspect.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/obsessive-compulsive-disorder-ocd-word-cloud-1786299122">Colored Lights/Shutterstock</a></span>
</figcaption>
</figure>
<h2>My experience of OCD</h2>
<p>From the age of 16, I have also suffered with thoughts that I later came to associate with OCD, but which began as invisible and tormenting. An article I wrote in 2014, entitled <a href="https://www.ocduk.org/the-unseen-obsession/">The Unseen Obsession</a>, described my experience of having left university midway through my studies due to a single thought that gathered “such power that I even ended up attacking my body in an attempt to eliminate its force”. I wrote:</p>
<blockquote>
<p>I have suffered with obsessional thoughts for the last four years, and can safely say that [OCD] is far from being about clean hands.</p>
</blockquote>
<p>My obsessions have taken many forms since my teenage years. They began with me wondering whether things really existed, whether my parents were really who they said they were, and whether I wanted to harm – and was a risk to – my family, friends, even my dog.</p>
<p>Many of us know what it is like to ruminate about a person, a conflict, or something else we feel anxious about. But for those with obsessional thoughts (diagnosed or otherwise), this is quite different to simply “overthinking”. As I attempted to explain in my article:</p>
<blockquote>
<p>Conversations falter as the thought leaps through your mind. Other topics seem less important, and time to yourself provides space to assess, analyse, and look for evidence of the thought being ‘true’ … [Obsessing] is like fighting: you push and shove your thoughts away and they come back with twice as much force. You spend time trying to avoid them and they pop up everywhere, taunting and mocking your failed attempt at running away.</p>
</blockquote>
<p>It took me six months of weekly therapy sessions before I felt able to voice my obsessional thought to my therapist – someone I had known for a number of years. My unwillingness to be open about it was not only tied up with feelings of shame about its taboo content, but also my inability to see such thinking as part of a recognised disorder.</p>
<p>The question of what constitutes OCD, why we understand – and misunderstand – it as we do, as well as my own experience of living with it, led me to study <a href="https://www.cambridge.org/core/journals/british-journal-for-the-history-of-science/article/visible-compulsions-ocd-and-the-politics-of-science-in-british-clinical-psychology-19481975/D431B7D6003860F9E6ABE50476BA46A4">how OCD became recognised and categorised as a mental health disorder</a>.</p>
<p>In particular, my research shows that there are important insights to be gained from the research decisions made by a group of influential clinical psychologists in south London in the early 1970s – shedding light on why so many people, myself included, still struggle to recognise and make sense of our obsessional thoughts.</p>
<h2>The origin of the concepts</h2>
<p>Categories of mental illness are not stable across time. As medical, scientific, and public knowledge about an illness changes, so does how it is experienced and diagnosed.</p>
<p>Prior to the 1970s, “obsessions” and “compulsions” did not exist in a unified category – rather, they appeared in an array of psychiatric classifications. At the start of the 20th century, for example, British doctor James Shaw <a href="https://www.cambridge.org/core/services/aop-cambridge-core/content/view/8D219344EF697D92E69BF9ED60F8508B/S000712500016204Xa.pdf/verbal-obsessions.pdf">defined</a> verbal obsessions as “a mode of cerebral activity in which a thought – mostly obscene or blasphemous – forces itself into consciousness”.</p>
<p>Such cerebral activity could, according to Shaw, arise in hysteria, <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/neurasthenia">neurasthenia</a>, or as a precursor to delusions. One of his patients – a woman who experienced “irresistible, obscene, blasphemous and unutterable thoughts” – was diagnosed with obsessional melancholia, a “form of insanity”.</p>
<p>The symptom arose from what Shaw defined as “nervous weakness”, an explanation that reflected the <a href="https://academic.oup.com/book/25373/chapter-abstract/192459930?redirectedFrom=fulltext">broader 19th-century view</a> that obsessional thoughts were indicative of a fragile nervous system – either inherited, or weakened through overwork, alcohol or promiscuous behaviour (described as “<a href="https://pubmed.ncbi.nlm.nih.gov/3514404/">degeneration theory</a>”). Notably, Shaw did not mention any form of repetitive behaviour in relation to these verbal obsessions.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bearded man holding a cigar" src="https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=844&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=844&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=844&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1061&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1061&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563989/original/file-20231206-15-nk8woa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1061&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sigmund Freud, founder of psychoanalysis.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Sigmund_Freud_LIFE.jpg">Max Halberstadt via Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>At a similar time to Shaw’s writings, Sigmund Freud, the Austrian founder of psychoanalysis, developed his psychoanalytic category of “<a href="https://journals.sagepub.com/doi/10.1177/0957154X9800903504">Zwangsneurose</a> – translated in Britain as "obsessional neurosis” and in the US as “compulsion neurosis”. In Freud’s <a href="https://www.mhweb.org/freud/ratman1.pdf">writings</a>, the “Zwang” referred to persistent ideas that emerged from a repressed conflict between unresolved childhood impulses (those of love and hate) and the critical self (ego).</p>
<p>Freud’s <a href="https://ia802907.us.archive.org/17/items/SigmundFreud/Sigmund%20Freud%20%5B1909%5D%20Notes%20Upon%20A%20Case%20Of%20Obsessional%20Neurosis%20%28The%20Rat%20Man%20Case%20History%29%28James%20Strachey%20Translation%201955%29.pdf">most famous case study</a>, published in 1909, featured the “Rat Man”, a former Austrian army officer who possessed a variety of elaborate symptoms. In the first instance, he had become obsessed that he would fall victim to a horrific rat-based punishment that had been recounted to him by a colleague. The patient also expressed that if he had certain desires such as a wish to see a woman naked, his already-deceased father “will be bound to die”.</p>
<p>The Rat Man was described by Freud as engaging in a “system of ceremonial defences” and “elaborate manoeuvres full of contradictions” that have been read by some as the behavioural aspects of what would become OCD. However, there are crucial differences between the “defences” of Freud’s client and the compulsions of OCD, including that the former largely involved thinking rather than acting, and were by no means consistent or stereotyped.</p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
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</figure>
<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
<hr>
<p>The psychoanalytic category of “obsessional neurosis” was adopted and modified in Britain during the first world war, and became a staple – but inconsistently defined – diagnosis in British psychiatric textbooks of the inter-war period. Up to the 1950s, the terms “obsession” and “compulsion” were being used interchangeably in psychiatric writing. The complexity surrounding their meaning is demonstrated in the <a href="https://www.google.co.uk/books/edition/Inquiries_in_Psychiatry_Clinical_and_Soc/JsZrAAAAMAAJ?hl=en">writings of Aubrey Lewis</a>, a leading figure in post-war British psychiatry, who referred to “obsessional illnesses” as being made up of “compulsive thoughts” and “compulsive inner speech”.</p>
<p>Like Freud, Lewis mentioned the “complex rituals” of the obsessional – such as the patient “who is perpetually putting himself in the greatest trouble to ensure that he never steps on a worm inadvertently”. But he cautioned against “the dangers of associating any kind of repetitious activity with obsessionality”, writing that “it certainly cannot be judged on behaviourist grounds”.</p>
<h2>Defining OCD by visible behaviour</h2>
<p>OCD began to emerge in the form we recognise it today from the early 1970s – and was established as a formal psychiatric disorder through its inclusion in the third and fourth editions of the American Psychiatric Association’s <a href="https://aditpsiquiatriaypsicologia.es/images/CLASIFICACION%20DE%20ENFERMEDADES/DSM-III.pdf">Diagnostic and Statistical Manual</a> (commonly known as DSM-III and DSM-IV) in 1980 and 1994.</p>
<p>The centrality of visible and measurable behaviours in the categorisation of OCD – particularly washing and checking – can be traced back to a series of experiments conducted by clinical psychologists in the early 1970s at the Institute of Psychiatry and the Maudsley Hospital in south London.</p>
<p>Under the direction of South African psychologist Stanley Rachman, the complex array of symptoms contained in the categories of obsessional illness and obsessional neurosis were divided into two: “visible” compulsive rituals, and “invisible” obsessional ruminations. While Rachman and his colleagues conducted a large research programme on compulsive behaviours, obsessions were relegated to the backburner.</p>
<p>For example, in <a href="https://www.sciencedirect.com/science/article/pii/000579677190009X">their investigation</a> of ten psychiatric inpatients diagnosed with obsessional neurosis, “compulsions had to be present for entry into the trial and patients complaining of ruminations were excluded” – a statement reiterated throughout subsequent experiments.</p>
<p>Indeed, this study did not merely require patients to exhibit some form of visible compulsion. The ten patients included were exclusively those with “visible handwashing” behaviour, which was viewed as the “easiest” symptom to experiment on. Likewise, the second round of studies only included patients who engaged in visible “checking” behaviour, such as whether a door was unlocked.</p>
<p>In a <a href="https://www.sciencedirect.com/science/article/pii/0005796771900088">1971 paper</a>, Rachman offered his rationale for taking this approach, explaining how “obsessional ruminators raise special problems for the clinical psychologist because of their subjective, private nature”. This, he argued, was in contrast with “the other main feature of obsessional neurosis, compulsive behaviour, which can be approached with greater ease. It is visible, has a predictable quality, and many reproducible analogies in animal research”.</p>
<p>Rachman viewed compulsions as “visible” and “predictable” in large part due to the way clinical psychology had developed as a new profession in Britain, at the Maudsley Hospital in particular, in the decades following the second world war. To differentiate their practice from the existing mental health professions of psychiatry (medically trained doctors specialising in mental health) and psychoanalysis (talking therapy derived from Freud), these early clinical psychologists presented themselves as “<a href="https://www.bps.org.uk/psychologist/eysenck-and-development-cbt">applied scientists</a>” who brought scientific methods from the laboratory to a clinical setting. Their conception of science was rooted in empiricism – with an emphasis on visibility, measurability and experimentation.</p>
<p>As part of this commitment to empirical science, these clinical psychologists adopted a <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0054288">model of anxiety</a> derived from 20th-century behaviourism. This focus on observable behaviour was <a href="https://www.cambridge.org/core/journals/journal-of-mental-science/article/abs/learning-theory-and-behaviour-therapy/38CA4A9BC0CA773F6BEE93EDDC71584F">viewed as</a> having much greater scientific value than psychoanalysis, which dealt with the “<a href="https://www.taylorfrancis.com/books/mono/10.4324/9780203766767/causes-cures-neurosis-psychology-revivals-eysenck-rachman">unverifiable</a>” and “unscientific” realm of thoughts and thinking.</p>
<p>So, when obsessional ruminations gained a renewed focus in the mid-1970s, it was through this lens of visible compulsive behaviours. Rachman and his colleagues started talking about “mental compulsions” (such as saying a good thought after a bad thought) as “equivalent to handwashing”- rather than focusing on the importance and content of these thoughts in their own right.</p>
<p>In the early 1980s, clinical psychology came under pressure from cognitive psychologists (those concerned with thinking and language) for its reductive focus on behaviour. But despite this move to <a href="https://www.sciencedirect.com/science/article/abs/pii/0005796785901056">include cognitive approaches</a>, the centrality of visible behavioural compulsions has continued to characterise perceptions of OCD in cultural and clinical domains. </p>
<p>This is perhaps most evident in media portrayals of the disorder – a critique taken up by cultural scholars such as <a href="https://www.tandfonline.com/doi/abs/10.1080/01639625.2013.872526">Dana Fennell</a>, who look at representations of OCD in TV and film.</p>
<p>The archetypal portrayal of OCD has <a href="https://www.ocduk.org/david-beckham-documentary-our-statement/">not been helped</a> by the recent publicity given to David Beckham and his <a href="https://www.mirror.co.uk/news/health/david-beckham-ocd-update-football-31102545">extensive tidying</a>. When I ask Abby what she thought about the <a href="https://www.theguardian.com/football/2023/apr/28/david-beckham-ocd-obsessive-compulsive-disorder-netflix-documentary">attention</a> that Beckham’s OCD was receiving in the media, she replies: “It’s so boring. It’s the same presentation that always gets thought of as OCD.”</p>
<h2>Limitations to the ‘gold standard’ treatment</h2>
<p>This archetypal portrayal of OCD also relates to how it is treated. The <a href="https://www.dovepress.com/getfile.php?fileID=54942">“gold standard” treatment</a> in the UK today is the behavioural technique of <a href="https://www.ocduk.org/overcoming-ocd/accessing-ocd-treatment/exposure-response-prevention/">exposure and ritual prevention</a> (ERP), either on its own or combined with cognitive therapy. ERP gained acceptance from the experiments of Rachman and colleagues in the early 1970s, when they were exclusively working with patients with observable behaviours.</p>
<p>One of their <a href="https://www.sciencedirect.com/science/article/abs/pii/S0005796772800032">key studies</a> involved patients from the Maudsley Hospital who repeatedly washed their hands. They were told to touch smears of dog excrement and put hamsters in their bags and in their hair, while being prevented from washing for increased lengths of time.</p>
<p>Such experiments were again governed by observability and measurability. The “success” of ERP treatment – and its perceived superiority over psychiatric and psychoanalytic methods – was demonstrated by a reduction in the patients’ visible handwashing behaviour.</p>
<p>Today, if you are diagnosed with OCD by a psychiatrist and given OCD-specialist treatment via the NHS, you will most likely be told to undergo the same kind of ERP procedure that hospital inpatients were experimentally given in the 1970s: touching a set of items that you fear (exposure) while being prevented from engaging in your usual compulsive behaviour.</p>
<p>An identical method is also used when it comes to obsessional thoughts. Patients are asked to identify their worrying obsession, then either expose themselves to provoking situations or repeat the thought in their mind without engaging in “mental compulsions” – such as counting, replacing a bad thought with a good thought, or trying to “solve” the content of the obsessional thought.</p>
<p>It’s certainly true that this form of behavioural therapy can be <a href="https://www.dovepress.com/getfile.php?fileID=54942">hugely helpful</a> in the treatment of OCD symptoms. Abby, after undergoing ERP for 14 years, said she had “developed a lot of practices around not giving into my [washing and checking] compulsions”.</p>
<p>I also found the approach beneficial in reducing the threatening quality of my obsessional thoughts. Repeating “I want to hurt my family” or “I don’t really exist” to myself over and over again, without actually trying to solve these issues, reduced the time I spent ruminating.</p>
<p>However, while being a huge advocate of ERP, Abby also observed that “sometimes when I get rid of a compulsion, it doesn’t mean I just get rid of the obsession.” While the “outward compulsions” disappear, “it doesn’t mean my mind stops cycling and mental questioning”.</p>
<p>Some contemporary clinicians have referred to ERP, designed around visible symptom reduction, as a “<a href="https://www.justinkhughes.com/wp-content/uploads/2021/03/ocd_texas_talk_with_molly_and_justin_2019__22common_pitfalls_of_erp_for_ocd_22.pdf">whack-a-mole technique</a>” – you get rid one symptom (obsession or compulsion) and another pops up.</p>
<p>ERP is frequently accompanied with cognitive therapy techniques, such as <a href="https://www.apa.org/pubs/books/supplemental/Treatment-for-Postdisaster-Distress/Handout-27.pdf">cognitive restructuring</a> (identifying beliefs and providing evidence for and against them), or being told that obsessions are “just thoughts”, that they are meaningless, and that you do not want to enact them.</p>
<p>Despite the success of cognitive-behaviour therapy (CBT) and ERP in scientific trials, a <a href="https://www.sciencedirect.com/science/article/pii/S0010440X21000018?via%3Dihub">major review of evidence</a> in 2021 questioned whether the effects of the approach in treating OCD had been overstated – reflecting the high proportion of OCD cases that are designated as “<a href="https://www.ncbi.nlm.nih.gov/books/NBK551808/">treatment resistant</a>”. </p>
<p>I also believe there are some crucial limitations to contemporary treatments for OCD. Exposure (ERP) techniques stem from a period in which thoughts were not being considered at all by clinical psychologists, while CBT designates the content of obsessional thoughts as unimportant. Matt, like me, has found that CBT “can only take you so far”, explaining:</p>
<blockquote>
<p>Part of this was that [CBT therapists] are so committed to the idea that thoughts don’t have meaning … [They] treat your symptom and once those are gone, you should get on with your life. I didn’t find that there was a way of thinking about [my] ruminations in the context of my whole life.</p>
</blockquote>
<h2>Experiences of alternative treatments</h2>
<p>So much of my understanding about OCD has changed since I first wrote about it for <a href="https://www.rethink.org/aboutus/">Rethink Mental Illness</a> almost a decade ago. Thinking about the historical development and categorisation of OCD has, it turns out, given me a greater sense of ease regarding this widely misunderstood condition. I feel less bound by our current conceptual frameworks, and more able to reflect on what I think is helpful in terms of how to successfully manage my obsessional thoughts.</p>
<p>For example, despite being warned away from psychoanalysis from a young age (my mum is a clinical psychologist, and psychologists are often fervently anti-psychoanalytic!), I have found psychoanalysis incredibly helpful in becoming comfortable with my thoughts. </p>
<p>This is because CBT typically focuses on present symptoms without looking into their meaning or how they relate to your personal history, and this comes into tension with my desire, as a historian, to think about the past. In contrast, psychoanalysis locates obsessional thoughts in history – pointing to childhood as a crucial point of psychic development. I have been able to understand my obsessions as the result of a deep childhood fear concerning the death of my loved ones, from which I developed a rigid desire for control.</p>
<p>As a young teenager trying to determine what was going on with him, Matt went to the public library and took out a <a href="https://ia903102.us.archive.org/15/items/petergay1989freudreader/Adam%20Phillips%20%5B2006%5D%20Penguin%20Freud%20Reader.pdf">Freud reader</a>. He describes this as “the worst possible thing for a 14-year-old to read”, as it made him believe “that I did really have all these [murderous suicidal] impulses and all my fears are true”.</p>
<p>Despite this experience, while training to become a social worker, he “got into psychoanalysis as an alternate way to think about therapy and think about my own experience”. For him, psychoanalysis revealed the opposite to the image of “OCD as handwashing”.</p>
<p>Instead, he says, it focused on the aspects of “obsessionality that are internal”, showing him that the “mind is so powerful that it can produce a lot of imaginary fears”. It also allowed him to see “OCD symptoms as wrapped up with my whole life”.</p>
<p>Particularly profound in psychoanalytic thought is the acceptance of the complexity and unknowability at the heart of human experience. As Jaqueline Rose, professor of humanities at Birkbeck, University of London, <a href="https://fitzcarraldoeditions.com/books/the-plague">wrote:</a>: </p>
<blockquote>
<p>Psychoanalysis begins with a mind in flight, a mind that cannot take the measure of its own pain. It begins, that is, with the recognition that the world – or what Freud sometimes refers to as ‘civilisation’ – makes demands on human subjects that are too much to bear.</p>
</blockquote>
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<a href="https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of a woman with eyes closed holding her temples." src="https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563998/original/file-20231206-17-435y0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/woman-touching-her-temples-hands-suffering-2156846349">Elena Abrazhevich/Shutterstock</a></span>
</figcaption>
</figure>
<p>This idea of “a mind in flight” has helped me think about my obsessions – whether my parents are really who they say they are; am I going to hurt those I love? – as part of a battle for certainty and control that is both unattainable and understandable, considering the world we live in.</p>
<p>The aim of psychoanalytic treatment is not to eradicate symptoms but to bring to light the difficult knots that humans have to deal with. Matt refers to psychoanalysis as acknowledging “a sort of messiness of the mind … I’ve found the psychoanalytic view of accepting your own messiness extremely helpful”. Rose similarly describes psychoanalysis as “the opposite of housework in how it deals with the mess we make”.</p>
<p>In the UK, psychoanalysis has been rejected within NHS service provision. And I believe this is, at least in part, a result of historical critiques levelled at it by clinical psychologists as they developed behaviour therapies to treat OCD in the late 20th century.</p>
<h2>‘A lot of emotion and sadness’</h2>
<p>While compulsive behaviour such as handwashing and checking is widely perceived as “representative” of OCD, the tormenting experience of having obsessional thoughts is still rarely acknowledged and discussed. The <a href="https://www.theguardian.com/commentisfree/2019/feb/21/ocd-sex-disorder-pure-rose-cartwright">shame and confusion</a> attached to such thoughts, coupled with the feeling of being misunderstood, make this an important issue to address, particularly when <a href="https://www.madeofmillions.com/articles/pure-o-an-exploration-into-a-lesser-known-form-of-ocd">misdiagnosis of OCD</a> is so high.</p>
<p>My <a href="https://www.cambridge.org/core/journals/british-journal-for-the-history-of-science/article/visible-compulsions-ocd-and-the-politics-of-science-in-british-clinical-psychology-19481975/D431B7D6003860F9E6ABE50476BA46A4">PhD on the history of OCD</a> has also showed me the ways in which psychological research shapes how we conceive of diagnostic categories – and consequently, ourselves. While psychology’s commitment to objectivity, empiricism and visibility has provided tools that are tremendously useful in the clinic, my research sheds lights on how the often-exclusive focus on visible symptoms has at times trumped the appreciation of the complex experience of having obsessional thoughts.</p>
<p>I first met Matt in 2019 at the first <a href="https://ocdinsociety.wixsite.com/home/2019">OCD in Society</a> conference, held at Queen Mary University of London, where he was giving a presentation on the “multiple meanings of OCD”. We discussed our own experiences of the disorder, and what we thought that history, psychoanalysis and anthropology could contribute to understandings of OCD.</p>
<p>Matt was 34, and he told me this was the first time he “had ever voiced the internal stuff out loud, and heard other people talk about it”. Recalling how this made him feel, he continued:</p>
<blockquote>
<p>I felt a lot of emotion and sadness. The isolation had been such a big part of my life that I had stopped noticing it. Then being out of the isolation was such a relief, it made me realise how bad it had been.</p>
</blockquote>
<hr>
<p><em>If you are experiencing suicidal thoughts and need support, you can call your GP, <a href="https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-use-111/">NHS 111</a>, or free helplines including <a href="https://www.samaritans.org/">Samaritans</a> (116 123), <a href="https://www.thecalmzone.net/">Calm</a> (0800 585858) or <a href="https://papyrus-uk.org/">Papyrus</a> (0800 068 4141).</em></p>
<p><em>In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found <a href="http://www.suicide.org/international-suicide-hotlines.html">here</a>.</em></p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<li><p><em><a href="https://theconversation.com/how-to-solve-our-mental-health-crisis-214776?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">How to solve our mental health crisis</a></em></p></li>
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<p class="fine-print"><em><span>Eva Surawy Stepney receives funding from the Arts and Humanities Research Council (AHRC) via the White Rose College of the Arts and Humanities (WRoCAH). </span></em></p>Research decisions made by clinical psychologists in the 1970s can help explain why so many people, myself included, struggle to make sense of our obsessional thoughts.Eva Surawy Stepney, PhD Candidate in History, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114172023-08-28T20:03:47Z2023-08-28T20:03:47ZTranscranial magnetic stimulation can treat depression. Developing research suggests it could also help autism, ADHD and OCD<p>Since the start of the COVID pandemic, there has been more attention given to problems of mental ill-health including depression <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01328-9/fulltext">than ever before</a>. A new therapeutic option, especially for depression, transcranial magnetic stimulation, is slowly helping to address some of these considerable unmet needs in our community. </p>
<p>Research is also exploring the use of transcranial magnetic stimulation in many other conditions, including obsessive compulsive disorder, autism, attention deficit hyperactivity disorder, chronic pain and perhaps to slow the progression of dementia symptoms.</p>
<p>What do we know so far about this emerging form of treatment? And is it living up to its promise for people with depression?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treating-mental-illness-with-electricity-marries-old-ideas-with-modern-tech-and-understanding-of-the-brain-podcast-195071">Treating mental illness with electricity marries old ideas with modern tech and understanding of the brain – podcast</a>
</strong>
</em>
</p>
<hr>
<h2>How does it work and who’s getting it now?</h2>
<p><a href="https://theconversation.com/what-is-repetitive-transcranial-magnetic-stimulation-and-how-does-it-actually-work-160771">Transcranial magnetic stimulation</a> involves the application of a series of magnetic pulses through a coil placed on the scalp. While the patient sits in a chair awake and relaxed, the magnetic field activates nerve cells in the brain, gradually changing the activity of brain circuits disrupted in depression. This is thought to help restore the normal interaction between brain regions.</p>
<p>Side effects are <a href="https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625#:%7E:text=Serious%20side%20effects%20are%20rare,t%20well%2Dprotected%20during%20treatment.">usually mild</a> and temporary. They may include scalp discomfort, headache, tingling or facial twitching, and feeling lightheaded for a short time after a treatment session.</p>
<p>There is consistent evidence for the <a href="https://journals.sagepub.com/doi/10.1177/00048674211043047">effectiveness</a> of transcranial magnetic stimulation treatment for acute episodes of depression. Its use is supported by many clinical trials as well as real-world studies showing benefits in more than <a href="https://pubmed.ncbi.nlm.nih.gov/32799106/">50% of patients receiving treatment</a>. It attracted Medicare funding several years ago and is now being progressively rolled out around Australia. </p>
<p>But there are several remaining problems with the use of transcranial magnetic stimulation treatment. First, it involves a patient coming into the clinic daily, Monday to Friday, for four to six weeks. This is inefficient and costly. </p>
<p>Both these problems may ultimately be solved through the development of what are referred to as “accelerated” protocols – treatments that give higher doses on fewer days. A patient may have four or five days of high-dose treatment in one week rather than having all of the treatment dose spread out over a month or more. </p>
<p><a href="https://www.nature.com/articles/s41386-023-01599-z">Studies</a> both locally and overseas have started to show more efficient delivery and <a href="https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.19070720">very rapid clinical benefits</a> with these new treatment regimes.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&rect=65%2C5%2C3928%2C1988&q=45&auto=format&w=1000&fit=clip"><img alt="man sits in lab setting with equipment on" src="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&rect=65%2C5%2C3928%2C1988&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The lasting effects and need for maintenance doses of transcranial magnetic stimulation need further study.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-transcranial-magnetic-stimulation-tms-experiment-426901186">Shutterstock</a></span>
</figcaption>
</figure>
<h2>What about for other conditions?</h2>
<p>Alongside the clinical rollout of transcranial magnetic stimulation for depression, research is increasingly demonstrating its potential value in other conditions. </p>
<p>A series of studies have demonstrated that a somewhat different type of transcranial magnetic stimulation, which is able to stimulate deeper regions of the brain but which still comes from a scalp based coil, can be effective in the treatment of symptoms in some patients with <a href="https://iocdf.org/about-ocd/ocd-treatment/tms/">obsessive compulsive disorder</a> (OCD). This is a critical development as many patients with OCD fail to improve with medication and psychological treatments and there are few new therapies in development for the condition. </p>
<p>Transcranial magnetic stimulation for OCD has been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8864803/#:%7E:text=Aside%20from%20MDD%2C%20the%20next,adults%20in%202017%20(DEN170078).">approved</a> for clinical use in the United States and is available in a limited number of clinical services in Australia.</p>
<p>The treatment is showing promise for <a href="https://www.mdpi.com/2077-0383/11/3/624">addiction disorders</a>, including the development of an approach using transcranial magnetic stimulation to <a href="https://www.sciencedirect.com/science/article/pii/S0165178123002901">help patients stop smoking</a>. The initial trial of this approach showed at least a doubling of the percentage of patients who did not smoke over the first six weeks. </p>
<p>Transcranial magnetic stimulation may also help people manage chronic pain. Multiple approaches that use the technology show promise and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0987705319301789?via%3Dihub">guidelines are emerging</a>, but a consistent clinical pathway has not yet been well defined.</p>
<p>A group of researchers across the country, led by <a href="https://tmsautism.com/">Professor Peter Enticott in Melbourne</a>, are conducting world-leading research trying to develop ways of using transcranial magnetic stimulation to help adolescent and adult patients with autism, especially to improve capacity for social understanding and interaction.</p>
<p>As clinical need escalates, early research is also exploring whether transcranial magnetic stimulation might alleviate symptoms of <a href="https://mecp.springeropen.com/articles/10.1186/s43045-022-00210-3">attention deficit hyperactivity disorder (ADHD)</a>. </p>
<p>Research has already demonstrated transcranial magnetic stimulation may improve, at least temporarily, thinking abilities in a range of disorders including <a href="https://www.frontiersin.org/articles/10.3389/fnagi.2022.984708/full">Alzheimer’s disease</a>. This is now being applied to see if it can improve attention for patients with ADHD. For now, this research remains in its infancy.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1689015899963961344"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/people-with-obsessive-compulsive-disorder-have-an-imbalance-of-brain-chemicals-our-discovery-could-mean-a-treatment-breakthrough-208549">People with obsessive-compulsive disorder have an imbalance of brain chemicals – our discovery could mean a treatment breakthrough</a>
</strong>
</em>
</p>
<hr>
<h2>Do the effects last?</h2>
<p>So far, the quality of the <a href="https://doi.org/10.1016/j.jad.2021.09.040">evidence</a> on the persistence of effects and the need for maintenance treatment with the use of transcranial magnetic stimulation in depression is patchy. Research is looking at whether ongoing transcranial magnetic stimulation less often (for example one treatment every two weeks) may prevent the recurrence of depression in patients who have responded well. <a href="https://pubmed.ncbi.nlm.nih.gov/31399997/">Preliminary studies</a> suggest maintenance treatment is effective, but there there have been insufficient high-quality studies to convince Medicare to provide a subsidy for it. </p>
<p>Medicare funding also does not fund the provision of transcranial magnetic stimulation for patients who experience the return of their depression on more than one occasion.</p>
<p>This is highly unusual. Patients with depression can have multiple courses of antidepressant medication, psychotherapy or electroconvulsive therapy based on similar levels of evidence. This is also true of most other medical therapies. </p>
<p>In clinical practice, and from the <a href="https://doi.org/10.1016/j.jad.2020.06.067">limited evidence available</a>, it seems clear that if a patient has responded on one occasion to transcranial magnetic stimulation, they are likely to again. Until this is resolved, patients are in an unenviable situation. They know there is an effective treatment that has worked for them already, but they can only access it at considerable expense or via lengthy private hospital admission.</p><img src="https://counter.theconversation.com/content/211417/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Fitzgerald is a founder of TMS Clinics Australia / Monarch Mental Health Group which provides rTMS therapy through 21 clinics in three states of Australia. He has received grant funding from the NHMRC to support clinical trials into the use of rTMS. He was the author of several applications to the Medicare Services Advisory Committee seeking an item number for rTMS therapy for depression which led to the current approval.</span></em></p>What do we know so far about this promising form of treatment and how it might help people with a range of neurological conditions? And is it living up to its promise for people with depression?Paul B. Fitzgerald, Professor of Psychiatry, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2085492023-06-28T13:09:38Z2023-06-28T13:09:38ZPeople with obsessive-compulsive disorder have an imbalance of brain chemicals – our discovery could mean a treatment breakthrough<figure><img src="https://images.theconversation.com/files/534549/original/file-20230628-29-ulshbt.jpg?ixlib=rb-1.1.0&rect=183%2C63%2C4917%2C3946&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">MRI brain scan.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mri-image-head-showing-brain-227580421">SpeedKingz/Shutterstock</a></span></figcaption></figure><p>People often jokingly say they’ve “got a bit of OCD” (obsessive-compulsive disorder) if they are overly organised or tidy. But OCD is actually a severe and disabling disorder characterised by obsessions – recurrent intrusive thoughts, impulses or images that are unwanted and anxiety provoking. This is often coupled with compulsions, which are ritualistic mental or physical actions. </p>
<p>Some people with OCD are engaged in rituals for much of their waking life and cannot even leave their homes. As the condition is difficult to treat, life with OCD can be extremely difficult.</p>
<p>But in our new research, <a href="https://www.nature.com/articles/s41467-023-38695-z">published in Nature Communications</a>, we discovered an imbalance in brain chemicals in OCD that could lead to radically different and improved treatments.</p>
<p>OCD affects around 3% of the population. The average age of onset is 19.5 years, which means that many cases go undetected in childhood and adolescence. NHS-recommended treatments include cognitive behavioural therapy and antidepressant drugs called selective serotonin re-uptake inhibitors (SSRIs), which <a href="https://www.nhs.uk/mental-health/conditions/obsessive-compulsive-disorder-ocd/overview/">boost the chemical serotonin</a> in the brain.</p>
<p>However, 50% of OCD patients don’t respond fully to SSRIs – meaning their symptoms are likely to continue to some extent. And at least <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495343/">eight weeks of sustained treatment</a> is typically needed before any meaningful clinical improvement can be seen.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Aviator Howard Hughes had crippling OCD." src="https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=790&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=790&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=790&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=992&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=992&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534548/original/file-20230628-30-awwgdh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=992&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Aviator Howard Hughes had crippling OCD.</span>
<span class="attribution"><span class="source">wikipedia</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>To be able to develop more effective treatments, it is crucial that we understand the chemical basis of OCD in the brain. Scientists <a href="https://academic.oup.com/book/24387/chapter-abstract/187317098?redirectedFrom=fulltext">have suspected</a> that this involves an imbalance between chemical messengers, or neurotransmitters, called
<a href="https://www.frontiersin.org/articles/10.3389/fnhum.2021.722323/full">glutamate</a> and gamma-aminobutyric acid <a href="https://www.medicalnewstoday.com/articles/326847#summary">(Gaba)</a> in certain brain regions.</p>
<p>While glutamate promotes communication between neurons, Gaba reduces or inhibits neural communication (calming the central nervous system and making us less inhibited). Imbalances in these chemicals can therefore make communications more or less difficult within neural circuits in the brain – potentially leading to symptoms such as compulsions and intrusive thoughts.</p>
<h2>Magnetic resonance spectroscopy</h2>
<p>To study glutamate and Gaba, we used a high-strength magnet (called 7-Tesla) to perform magnetic resonance spectroscopy. This technique detects radio frequency electromagnetic signals produced by the atomic nuclei in molecules. This helps scientists to measure what kind of chemicals exist there – and their concentration.</p>
<p>This allowed us to detect and measure glutamate and Gaba levels separately in different brain regions. We specifically looked at two brain regions toward the front of the brain called the anterior cingulate cortex (ACC) and the supplementary motor area (SMA). </p>
<p>That’s because previous studies had already shown that these areas, involved in actions, <a href="https://www.sciencedirect.com/science/article/pii/S089662731930073X">are affected in OCD</a>. Activity in the ACC changes in response to reward or punishment, guiding future decision-making. The SMA is involved in the coordination of motor sequences and seems to have a role in the production of habits.</p>
<p>We found an imbalance between glutamate and Gaba levels in a group of 31 patients with OCD in the frontal regions of the brain. Specifically, OCD patients had increased levels of glutamate and lower levels of Gaba in the ACC. This means that they had very high levels of neural communication in the area, potentially making it hyperactive. They also had a disrupted balance between these chemicals in the SMA. </p>
<p>Importantly, the clinical severity of compulsive symptoms of OCD correlated with the glutamate levels we measured in the SMA. Self-rated questionnaires of compulsive tendencies by both people with OCD and those in a healthy volunteer control group also correlated with glutamate in this region.</p>
<p>For the ACC, we found that that people’s proneness to habit (which is closely linked to compulsion) <a href="https://www.nature.com/articles/s41467-023-38695-z">correlated with the glutamate/Gaba balance</a> that we discovered. </p>
<h2>Future treatments</h2>
<p>The finding raises hopes for better treatments for OCD, focusing on re-balancing glutamate and Gaba levels in key brain regions. Some genetic <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5642460/">evidence also suggests</a> that the genes of people with OCD that regulate glutamate levels in the brain may be impaired. </p>
<p>One possible approach is to use drugs that reduce the release of glutamate from nerve cells at certain receptors in the brain (known as metabotropic glutamate 2 receptors). These are receptors that glutamate binds to, they suppress activity in the nerve cells that use it as a chemical transmitter. </p>
<p>One such existing class of drugs works on this receptor and <a href="https://pubmed.ncbi.nlm.nih.gov/25890643/">has already been tried</a> safely in humans. However, these drugs have not yet been trialled in patients with OCD. </p>
<p>In patients with extremely severe OCD, for whom all other usual treatments have failed, surgeons have actually removed the ACC. This is one of the very few examples of where psychosurgery has been shown to be beneficial – <a href="https://pubmed.ncbi.nlm.nih.gov/12662251/">with few reported adverse effects</a> on cognition. </p>
<p>In the future, though, rather than removing the ACC in such patients, deep brain stimulation through implanted electrodes could be used to reduce activity in this region.</p>
<p>And for less severely impaired patients where such drastic treatments are not justified, there may be therapeutic possibilities of using “<a href="https://theconversation.com/magnet-therapy-for-depression-is-available-on-the-nhs-heres-how-it-works-206022">transcranial magnetic stimulation</a>”. This treatment is administered via a magnetic coil positioned against the scalp to readjust the chemical balance and activity of these neural circuits.</p>
<p>In future, if OCD is diagnosed early in the course of the illness – and the chemical imbalance we have discovered is also detected – then these new treatments offer hope for improved quality of life and wellbeing for patients the disorder.</p><img src="https://counter.theconversation.com/content/208549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Trevor Robbins is in receipt of a research grant from Sirgartan plc for whom he also consults. His work was supported by the Wellcome Trust. He is also a consultant for Cambridge Cognition and is Chair of the Orchard OCD Charity research committee. </span></em></p><p class="fine-print"><em><span> Barbara Jacquelyn Sahakian receives funding from the Leverhulme Trust and the Lundbeck Foundation. Her research work is conducted within the NIHR Cambridge Biomedical Research Centre (BRC) Mental Health and Neurodegeneration Themes and the NIHR MedTech and in vitro diagnostic Co-operative (MIC). She consults for Cambridge Cognition. Cambridge Enterprise has technology transferred Decoder to PEAK and PopReach. She receives royalties from PopReach.
She is a member of the Orchard committee and a member of the NICE Committee on Harmful Gambling.</span></em></p><p class="fine-print"><em><span>Marjan Biria does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Completely new forms of drugs may soon be available to treat obsessive-compulsive disorder.Trevor Robbins, Professor of Neuroscience, University of CambridgeBarbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeMarjan Biria, Research Fellow of Mental Health Neuroscience, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2074012023-06-25T13:34:53Z2023-06-25T13:34:53ZMaking pride more inclusive means creating space for 2SLGBTQ+ people with disabilities<figure><img src="https://images.theconversation.com/files/532792/original/file-20230619-19-gs4r05.jpg?ixlib=rb-1.1.0&rect=27%2C0%2C4585%2C3070&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Volunteers carry a large rainbow flag during the 2019 Pride Parade in Toronto.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Lahodynskyj</span></span></figcaption></figure><p>Pride month is a celebratory time for many queer people. It is an opportunity for greater visibility in the public sphere. Although 2SLGBTQ+ people are becoming more accepted, those living with disabilities still struggle to be seen and heard.</p>
<p>Queer disabled people, particularly those with invisible disabilities like autism, attention deficit hyperactivity disorder or obsessive-compulsive disorder, are sometimes faced with the complex decision of whether or not to come out. That would often mean battling false stereotypes that <a href="https://www.bbc.com/news/stories-55586657">disabled and autistic people cannot be queer</a>.</p>
<p>Previous studies have shown how <a href="https://doi.org/10.5772/intechopen.95964">mainstream queer spaces can be inaccessible and not accepting of disabled people</a>. For instance, in <a href="https://doi.org/10.1080%2F15532739.2019.1594484">one study</a> from the United States, LGBTQ+ autistic people reported: </p>
<blockquote>
<p>feeling “othered,” discredited [and] tolerated rather than accepted.</p>
</blockquote>
<p>As a consequence, some disabled people choose to avoid disclosing their disability in queer spaces to avoid negative responses and rejection. At the same time, disabled communities can lack supports appropriate for 2SLGTBQ+ people and <a href="https://doi.org/10.3390/ijerph17218080">even present homophobic attitudes</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in a wheelchair with people walking carrying placards." src="https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People with disabilities attending a Pride Parade in Santa Pola, Spain in July 2022. Mainstream queer spaces can be inaccessible and not accepting of disabled people.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Feeling like outsiders in their own communities</h2>
<p><a href="https://thesocietypages.org/ccf/2022/07/19/still-being-left-behind-the-intimate-lives-of-queer-disabled-people/">Through our research</a>, we have heard how 2SLGTBQ+ people with developmental and mental disabilities struggle to find space to explore their identities, meet intimate partners, find community and form a sense of belonging. However, despite these struggles, their desire for community was clear.</p>
<p>Some disabled people reported feeling like outsiders in queer spaces and communities. As a participant noted: “I didn’t really want to participate in queer spaces because I felt like an interloper. I felt like I did not belong.” </p>
<p>This feeling of exclusion is further accentuated by the fact that, as some of our participants highlighted, <a href="https://www.cbc.ca/radio/nowornever/accessibility-in-action-meet-people-fighting-for-access-to-a-full-life-1.6491088/i-m-queer-and-disabled-pride-isn-t-accessible-for-me-1.6497282">Pride events can be inaccessible to disabled people</a>.</p>
<p>Participants also spoke about wanting more representation of disabled and autistic people within queer spaces. One participant noted that most queer spaces “are very predominantly white and predominantly able-bodied, predominantly a certain beauty standard, and all those things…people with disabilities may or may not fit that criteria for the queer communities, especially as a romantic partner.”</p>
<p>People with disabilities can sometimes find queer spaces, like bars and dance clubs, inaccessible due to loud noises, lack of open spaces and strong scents. Connecting with the broader 2SLGBTQ+ community is challenging because <a href="http://dx.doi.org/10.13140/RG.2.2.16004.91528">2SLGBTQ+ events are not always welcoming to their needs</a>.</p>
<p>Such sentiments are echoed by other research. <a href="https://doi.org/10.1007/s10803-020-04696-w">In another study with autistic adults</a>, participants talked about how both the disabled and queer communities can sometimes ostracize autistic people rather than being “open-minded” and “accepting” spaces. </p>
<p>Having a community that supports and affirms your identities is important and <a href="https://doi.org/10.1093/heapro/dax016">good for mental health</a>. For those who are disabled and queer, being left out of 2SLGBTQ+ spaces means they do not receive the benefits of feeling like they belong. </p>
<p>More importantly, folks in the community remind us that real accessibility means more than building a ramp to access a building. Meaningfully inviting 2SLGTBQ+ people with disabilities involves non-disabled queer people doing their homework, making meaningful space and <a href="https://digitalcommons.wcl.american.edu/jgspl/vol28/iss3/2/?utm_source=digitalcommons.wcl.american.edu%2Fjgspl%2Fvol28%2Fiss3%2F2&utm_medium=PDF&utm_campaign=PDFCoverPages">addressing their own ableism</a>.</p>
<figure class="align-center ">
<img alt="A man in a wheelchair waves a rainbow flag while other people wave him on." src="https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&rect=27%2C32%2C3602%2C2383&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man in a wheelchair at the Toronto Pride Parade in June 2019. LGBTQ+ people with disabilities can sometimes feel like outsiders in the community.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Making queer spaces more accessible</h2>
<p>Participants from <a href="https://doi.org/10.1007/s10803-020-04696-w">various</a> <a href="https://doi.org/10.1080%2F15532739.2019.1594484">studies</a> have shared suggestions for making queer spaces more accessible. This includes creating <a href="https://www.autismbc.ca/blog/intro-to-sensory-friendly/">sensory-friendly spaces</a>: for instance, offering noise-free areas, avoiding specific colours and patterns, reducing visual overload, relying on natural or dim lighting or creating opportunities for participation through online spaces.</p>
<p>Above all, <a href="https://www.cbc.ca/news/canada/saskatchewan/pride-2023-saskatchewan-accessibility-1.6860787">people want access to more spaces where disabled people can feel safe and included</a>. They do not wish to have to fight for the right to exist in queer spaces safely.<br>
2SLGBTQ+ spaces should inherently be where people can learn more about different identities and build communities, not spaces of exclusion. </p>
<p>There is a need for greater solidarity between queer, neurodiverse and disabled communities. More importantly, it is essential for queer communities to be proactive. Why wait until someone requests accommodations to take action? Instead, we should educate ourselves about disability, access and accessibility.</p>
<p>Disabled people should be meaningfully invited into queer spaces. It is crucial to have spaces and opportunities that are inclusive and celebratory for everyone. Such were the intentions of activists like <a href="https://www.them.us/story/brenda-howard">Brenda Howard</a> who paved the way for the Pride celebrations we have today. Intrinsically we are a community full of diversity, and that diversity is something to celebrate.</p><img src="https://counter.theconversation.com/content/207401/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alan Santinele Martino receives funding from the Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Emily Coombs does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Queer disabled people struggle to be seen in queer spaces that often do not accommodate them.Alan Santinele Martino, Assistant Professor, Community Rehabilitation and Disability Studies, University of CalgaryEmily Coombs, Master's student, Werklund School of Education, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1966512023-03-29T00:56:43Z2023-03-29T00:56:43ZObsessive compulsive disorder is more common than you think. But it can take 9 years for an OCD diagnosis<figure><img src="https://images.theconversation.com/files/511868/original/file-20230223-25-gc8koi.jpg?ixlib=rb-1.1.0&rect=1%2C5%2C997%2C770&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-obsessive-compulsive-disorder-placing-corn-1838649955">Shutterstock</a></span></figcaption></figure><p>Obsessive compulsive disorder, or OCD, is a <a href="https://www.sciencedirect.com/science/article/abs/pii/S2211364916301579">misunderstood</a>
mental illness despite affecting <a href="https://pubmed.ncbi.nlm.nih.gov/18725912">about one in 50 people</a> – that’s about half a million Australians.</p>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/00050067.2023.2189003">new research</a> shows how long and fraught the path to diagnosis and treatment can be. </p>
<p>This initial study showed it takes an average of almost nine years to receive a diagnosis of OCD and about four months to get some form of help.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-ocd-in-a-pandemic-doesnt-necessarily-get-worse-with-all-that-extra-hand-washing-157961">No, OCD in a pandemic doesn't necessarily get worse with all that extra hand washing</a>
</strong>
</em>
</p>
<hr>
<h2>What is OCD?</h2>
<p>OCD affects children, adolescents and adults. <a href="https://www.nature.com/articles/mp200894">About 60%</a> report symptoms before the age of 20.</p>
<p>One misconception is that OCD is mild: someone who is extra tidy or likes cleaning. You might have even heard someone say they are “<a href="https://theconversation.com/you-cant-be-a-little-bit-ocd-but-your-everyday-obsessions-can-help-end-the-conditions-stigma-49265">a little bit OCD</a>” while joking about having beautiful stationery.</p>
<p>But OCD is not enjoyable. Obsessions are highly distressing and there are repetitive, intrusive thoughts a person with OCD can’t control. They might believe, for instance, they or their loved ones are in grave danger. </p>
<p><a href="https://iocdf.org/about-ocd/">Compulsions</a> are actions that temporarily alleviate, but ultimately exacerbate, this distress, such as checking the door is locked. People with OCD spend hours each day consumed by this cycle, instead of their normal activities, such as school, work or having a social life. </p>
<p>It can also be very distressing for <a href="https://www.tandfonline.com/doi/abs/10.1586/ern.11.200">family members</a> who often end up completing rituals or providing excessive reassurance to the person with OCD.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/reel/Cl7ElJqBg4f","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-cant-be-a-little-bit-ocd-but-your-everyday-obsessions-can-help-end-the-conditions-stigma-49265">You can't be 'a little bit OCD' but your everyday obsessions can help end the condition's stigma</a>
</strong>
</em>
</p>
<hr>
<h2>How is it diagnosed?</h2>
<p>People with OCD often don’t tell others about their disturbing thoughts or repetitive rituals. They often feel <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/%28SICI%291099-0879%28199905%296%3A2%3C80%3A%3AAID-CPP188%3E3.0.CO%3B2-C">ashamed or worried</a> that by telling someone their disturbing thoughts, they might become true.</p>
<p>Doctors <a href="https://www.ncbi.nlm.nih.gov/books/NBK56470/#ch2">don’t always ask about</a> OCD symptoms when people first seek treatment. </p>
<p>Both lead to delays getting correctly diagnosed.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1399443462152404993"}"></div></p>
<p>When people do feel comfortable talking about their OCD symptoms, a diagnosis might be made by a GP, psychologist or other health-care professional, such as a psychiatrist. </p>
<p>Sometimes OCD can be <a href="https://link.springer.com/article/10.1007/s10566-009-9092-8">tricky to differentiate</a> from other conditions, such as eating disorders, anxiety disorders or autism. </p>
<p>Having an additional mental health diagnosis <a href="https://www.nature.com/articles/s41572-019-0102-3">is common</a> in people with OCD. In those cases, a health-care provider experienced in OCD is helpful. </p>
<p>To diagnose OCD, the health professional asks people and/or their families questions about the presence of obsessions and/or compulsions, and how this impacts their life and family. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-than-a-habit-when-to-worry-about-nail-biting-skin-picking-and-other-body-focused-repetitive-behaviours-102263">More than a habit? When to worry about nail biting, skin picking and other body-focused repetitive behaviours</a>
</strong>
</em>
</p>
<hr>
<h2>How is it treated?</h2>
<p>After someone receives a diagnosis, it helps to learn more about OCD and what treatment involves. Great places to start are the <a href="https://iocdf.org">International OCD Foundation</a> and <a href="https://www.ocduk.org">OCD UK</a>. </p>
<p>Next, they will need to find a health-care provider, usually a psychologist, who offers a special type of psychological therapy called “exposure and response prevention” or ERP.</p>
<p>This is a type of
<a href="https://theconversation.com/explainer-what-is-cognitive-behaviour-therapy-37351">cognitive-behavioural therapy</a> that is a <a href="https://doi.org/10.1016/j.jocrd.2021.100684">powerful, effective treatment</a> for OCD. It’s recommended people with OCD try this first.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man with dreadlocks sitting on sofa talking to therapist" src="https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A type of psychological therapy known as ‘exposure and response prevention’ is recommended first.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/positive-black-man-talking-to-female-therapist-5699421/">Alex Green/Pexels</a></span>
</figcaption>
</figure>
<p>It involves therapists helping people to understand the cycle of OCD and how to break that cycle. They support people to deliberately enter anxiety-provoking situations while resisting completing a compulsion. </p>
<p>Importantly, people and their ERP therapist <a href="https://pubmed.ncbi.nlm.nih.gov/18005936/">decide together</a> what steps to take to truly tackle their fears. </p>
<p>People with OCD learn new thoughts, for example, “germs don’t always lead to illness” rather than “germs are dangerous”.</p>
<p>There are a range of medications that also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967667/">effectively</a> <a href="https://pubmed.ncbi.nlm.nih.gov/27663940/">treat</a> OCD. But more research is needed to know more about when a medication should be added. For most people these are best considered a “boost” to help ERP.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/brain-scans-reveal-why-it-is-so-difficult-to-recover-from-ocd-and-hint-at-ways-forward-74092">Brain scans reveal why it is so difficult to recover from OCD – and hint at ways forward</a>
</strong>
</em>
</p>
<hr>
<h2>But not everything goes to plan</h2>
<p>Delays in being diagnosed is only the start:</p>
<ul>
<li><p>treatment is challenging to access. Only <a href="https://www.sciencedirect.com/science/article/abs/pii/S0887618518301038?via%3Dihub">30% of clinicians</a> in the United States offer ERP therapy. There is likely a similar situation in Australia</p></li>
<li><p>many people receive therapies that appear credible, <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/cpsp.12337?casa_token=Wn3bgnvINSsAAAAA%3A2sqam0BKtCzFA680_f6ln4scp1SKVpN_cOB6Tg8vQyEiNDZPwS-Z-NNveLelKYF6iz4PFqQSXyHKZYJS">but lack evidence</a>, such as general cognitive therapy that is not tailored to the mechanisms maintaining OCD. Inappropriate treatments waste valuable time and effort that the person could use to recover. Ineffective treatments can make OCD symptoms worse</p></li>
<li><p>even when someone receives first-line, evidence-based treatments, <a href="https://www.sciencedirect.com/science/article/pii/S0005796722001413?via%3Dihub">about 40-60%</a> of people don’t get better</p></li>
<li><p>there are no Australian clinical treatment guidelines, nor state or national clinical service plans for OCD. This makes it hard for health-care providers to know how to treat it</p></li>
<li><p>there has been <a href="https://journals.sagepub.com/doi/full/10.1177/00048674221125595">relatively little research funding</a> spent on OCD in the past ten years, compared with, for example, psychosis or dementia.</p></li>
</ul>
<h2>What can we do?</h2>
<p>Real change demands collaboration between health-care professionals, researchers, government, people with OCD and their families to advocate for proportionate funding for research and clinical services to:</p>
<ul>
<li><p>deliver public health messaging to improve general knowledge about OCD and reduce the stigma so people feel more comfortable disclosing their worries</p></li>
<li><p>upskill and support health professionals to speed up diagnosis so people can receive targeted early intervention</p></li>
<li><p>support health-care professionals to offer evidence-based treatment for OCD, so more people can access these treatments</p></li>
<li><p>develop state and national service plans and clinical guidelines. For example, the Australian government funds the <a href="https://nedc.com.au/">National Eating Disorders Collaboration</a> to develop and implement a nationally consistent approach to preventing and treating eating disorders</p></li>
<li><p>research to discover new, and enhance existing, treatments. These include ones for people who don’t get better after “exposure and response prevention” therapy.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">Seeing a psychologist on Medicare? Soon you'll be back to 10 sessions. But we know that's not often enough</a>
</strong>
</em>
</p>
<hr>
<h2>What if I think I have OCD?</h2>
<p>The most common barrier to getting help is not knowing who to see or where to go. Start with your GP: tell them you think you might have OCD and ask to discuss treatment options. These might include therapy and/or medication and a referral to a psychologist or psychiatrist.</p>
<p>If you choose therapy, it’s important to find a clinician that offers specific and effective treatment for OCD. To help, we’ve started <a href="https://ocd.org.au/directory">a directory</a> of clinicians with a special interest in treating OCD. </p>
<p>You <a href="https://iocdf.org/ocd-finding-help/how-to-find-the-right-therapist/#:%7E:text=Tips%20for%20Finding%20the%20Right%20Therapist&text=Also%2C%20remember%20that%20some%20therapists,the%20phone%20or%20in%20person">can ask</a> any potential health professional if they offer “exposure and response prevention”. If they don’t, it’s a sign this isn’t their area of expertise. But you still can ask them if they know of a colleague who does. You might need to call around, so hang in there. Good treatment can be life changing.</p>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/196651/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Iain Perkes is employed by UNSW, Sydney and the Sydney Children's Hospitals Network. He receives funding from Rotary Mental Health, the Mindgardens Neuroscience Network, National Health and Medical Research, the Tourette's Association of America, and the New South Wales Higher Education and Training Institute.</span></em></p><p class="fine-print"><em><span>David Cooper was funded by the UNSW Scientia PhD scholarship for his time on this article. David is also a clinical psychologist in private practice.</span></em></p><p class="fine-print"><em><span>Jessica Grisham receives funding from the Australian Research Council and Rotary Mental Health. </span></em></p><p class="fine-print"><em><span>Katelyn Dyason receives funding from Rotary Mental Health, and was funded by Mindgardens Neuroscience Network for her time on this article. </span></em></p><p class="fine-print"><em><span>Lara Farrell receives funding from Rotary Mental Health, National Health and Medical Research Council (NHMRC), and Medical Research Future Fund (MRFF). </span></em></p><p class="fine-print"><em><span>Lizzie Manning receives funding from National Health and Medical Research Council (NHMRC), Australian Research Council (ARC) and Tourette Association of America (TAA). </span></em></p>People can be reluctant to discuss symptoms with their doctor. When they do, their symptoms can be mistaken for other illnesses. Even when people are diagnosed, they don’t always get the right treatment.Iain Perkes, Senior Lecturer, child and adolescent psychiatry, UNSW SydneyDavid Cooper, PhD Candidate, UNSW SydneyJessica Grisham, Professor in Psychology, UNSW SydneyKatelyn Dyason, Project manager and psychologist, School of Psychiatry, UNSW SydneyLara Farrell, Associate Professor and Clinical Psychologist, Griffith UniversityLizzie Manning, Lecturer in Physiology and Neuroscience, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1993842023-02-10T13:52:21Z2023-02-10T13:52:21ZUse of psychedelics to treat PTSD, OCD, depression and chronic pain – a researcher discusses recent trials, possible risks<figure><img src="https://images.theconversation.com/files/508513/original/file-20230206-29-xiko4j.jpg?ixlib=rb-1.1.0&rect=89%2C0%2C7336%2C3540&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are some possible health issues with the drugs, including cardiovascular risks.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/creative-background-royalty-free-image/1352156068?phrase=PSYCHEDELICS&adppopup=true">wildpixel/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>New research is exploring whether psychedelic drugs, taken under strict medical supervision, might help in treating post-traumatic stress disorder, chronic pain, depression and obsessive-compulsive disorder. SciLine interviewed <a href="https://profiles.ucsf.edu/jennifer.mitchell">Dr. Jennifer Mitchell</a> – a professor in the Departments of Neurology and Psychiatry & Behavioral Science in the School of Medicine at the University of California, San Francisco – to discuss what scientists have found so far about the effectiveness of these drugs in treating these disorders and how they might safely be administered.</em></p>
<figure>
<iframe src="https://player.vimeo.com/video/794881597" width="500" height="281" frameborder="0" webkitallowfullscreen="" mozallowfullscreen="" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr. Jennifer Mitchell discusses psychedelic medicine.</span></figcaption>
</figure>
<p><em>The Conversation has collaborated with SciLine to bring you highlights from the discussion, which have been edited for brevity and clarity.</em></p>
<p><strong>What are psychedelic drugs and how do they work?</strong></p>
<p><strong>Jennifer Mitchell:</strong> Psychedelic <a href="https://www.verywellmind.com/types-of-psychedelic-drug-22073">basically means “mind manifesting</a>,” suggesting that the compound assists one in uncovering subject matter that perhaps is otherwise deeply hidden from the conscious mind. </p>
<p>It’s a slightly different term from hallucinogen, which you see used almost interchangeably at times with the term psychedelic. </p>
<p>A hallucinogen by definition is something that makes you see, hear, smell something that isn’t otherwise there, so you can imagine there’s a lot of overlap between psychedelics and hallucinogens. </p>
<p><strong>Which types of psychedelic drugs are being studied by researchers for potential therapeutic use?</strong></p>
<p><strong>Jennifer Mitchell:</strong> The two most well studied drugs at this point are MDMA and psilocybin. </p>
<p><a href="https://nida.nih.gov/publications/drugfacts/mdma-ecstasymolly">MDMA</a> is being evaluated mainly for treatment of post-traumatic stress disorder treatments, and <a href="https://adf.org.au/drug-facts/psilocybin/">psilocybin</a> mainly for treatment of resistant depression and major depressive disorder. </p>
<p>MDMA is the furthest along because there’s phase 3 data (data from late-stage research) and the possibility that a new drug application would be submitted to the FDA sometime later this year. </p>
<p><a href="https://www.dea.gov/factsheets/lsd">LSD</a> is also being evaluated for a number of different indications, most notably obsessive-compulsive disorder. </p>
<p>And then a couple of sort of heavier hitters are now being tested in primarily healthy control populations, including drugs like <a href="https://clinicaltrials.gov/ct2/results?cond=&term=mescaline&cntry=&state=&city=&dist=">mescaline</a> and <a href="https://clinicaltrials.gov/ct2/results?cond=&term=ayahuasca&cntry=&state=&city=&dist=">ayahuasca</a>.</p>
<p><strong>What have scientists discovered about whether these drugs are effective in treating health problems like PTSD or chronic pain?</strong></p>
<p><strong>Jennifer Mitchell:</strong> The drugs so far <a href="https://doi.org/10.1038/s41591-021-01336-3">appear to be quite effective</a>. I think one key, though, is that they’re typically being administered in conjunction with some form of psychotherapy. </p>
<p>So it’s important to keep that in mind when we look at the <a href="https://doi.org/10.1016/j.eclinm.2022.101809">results from some of these recent trials</a> that these are not drugs that are being administered in isolation. You are not taking home a bottle of pills and taking those twice a day as you would, say, an antidepressant. These are administered in a very particular way.</p>
<p><strong>What is involved in therapeutic treatment using these drugs?</strong></p>
<p><strong>Jennifer Mitchell:</strong> Typically, prior to taking the drug at all, subjects participate in a number of preparatory sessions so that they understand a little bit about what is going to happen on an experimental session day. </p>
<p>And then subjects come into a room that looks very much like a comfortable living room, and they spend all day there. The drug is administered typically in the morning. For psilocybin, you’re looking at a six-hour dosing session, and for MDMA, an eight-hour dosing session. </p>
<p>You are in the company of a group of trained providers: therapists, psychedelic facilitators, psychiatrists and clinical research coordinators.</p>
<p><strong>What are the potential risks of using psychedelic drugs for therapeutic purposes?</strong></p>
<p><strong>Jennifer Mitchell:</strong> One concern we’ve had is cardiovascular risk, and so we are taking great care in some of the clinical trials at present <a href="https://doi.org/10.1002/cpdd.796">to evaluate cardiovascular burden</a>, including heart attack risk, during and after the experiment. This evaluation includes tracking the heart rate and blood pressure of the participants.</p>
<p>In addition, researchers are worried about suicidality, in part because these are treatment-resistant populations that we’re starting off with, and so there’s a concern that perhaps, if they’re destabilized – either by the psychedelic, or just by tapering off their other meds in order to be part of a psychedelic trial – that we could run the risk of suicidality. </p>
<p>Lastly, I think the FDA has been concerned about the possibility that psychedelics are addictive, and so we’ve been following up with study participants to ensure that they aren’t engaging in drug seeking or drug taking outside of the study.</p>
<p><strong>What do we know about the safety of taking psychedelics outside the clinical context?</strong></p>
<p><strong>Jennifer Mitchell:</strong> I think we’ve all heard stories from the ‘60s and '70s of people taking psychedelics and <a href="https://www.verywellmind.com/what-is-a-bad-trip-22071">having very bad experiences</a>. What we know now is that the environment in which you take the psychedelic is of the utmost importance. It’s not appropriate at this point to try to take some of these substances or replicate some of these protocols on your own without oversight. </p>
<p><em>Watch the <a href="https://www.sciline.org/mental-health/psychedelic-medicine/">full interview</a> to hear more about psychedelic medicine.</em></p>
<p><em><a href="https://www.sciline.org/">SciLine</a> is a free service based at the nonprofit American Association for the Advancement of Science that helps journalists include scientific evidence and experts in their news stories.</em></p><img src="https://counter.theconversation.com/content/199384/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Mitchell has received funding from MAPS and currently serves on the Research Advisory Panel within the California Department of Justice.</span></em></p>The early research suggests the drugs might be effective for some conditions. But scientists have safety concerns.Jennifer Mitchell, Professor of Neurology, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1950712022-11-24T11:09:42Z2022-11-24T11:09:42ZTreating mental illness with electricity marries old ideas with modern tech and understanding of the brain – podcast<figure><img src="https://images.theconversation.com/files/497106/original/file-20221123-26-b9b1b1.png?ixlib=rb-1.1.0&rect=64%2C27%2C962%2C556&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In deep brain stimulation, electrodes – the pale white lines – are implanted into a patient's brain and connected to a battery in a person's chest.
</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:X-ray_of_deep_brain_stimulation_in_OCD,_L.png#/media/File:X-ray_of_deep_brain_stimulation_in_OCD,_L.png">Jmarchn/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Mental illnesses such as obsessive compulsive disorder, depression and addiction are notoriously hard to treat and often don’t respond to drugs. But a new wave of treatments that stimulate the brain with electricity are showing promise on patients and in clinical trials. In this episode of <a href="https://theconversation.com/uk/topics/the-conversation-weekly-98901">The Conversation Weekly</a> podcast, we talk to three experts and one patient about the history of treating mental illness, how new technology and deeper understanding of the brain are leading to better treatments and where the neuroscience of mental illness is headed next. </p>
<iframe src="https://embed.acast.com/60087127b9687759d637bade/637f346774e2da0012db0f5e" frameborder="0" width="100%" height="190px"></iframe>
<p><iframe id="tc-infographic-561" class="tc-infographic" height="100" src="https://cdn.theconversation.com/infographics/561/4fbbd099d631750693d02bac632430b71b37cd5f/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>It’s not uncommon to hear people joke about how their “OCD” makes them want to straighten a crooked picture or clean a smudge on a countertop, but for people actually living with severe obsessive compulsive disorder, the reality is anything but funny.</p>
<p><a href="https://som.ucdenver.edu/Profiles/Faculty/Profile/30555">Moksha Patel</a> is a physician and professor at the University of Colorado and has severe OCD. “OCD was really taking over my life. The most obvious of my symptoms were not being able to use any public restrooms, showering for an hour after using the restrooms each time and using chemical cleaners on my skin and my mouth,” he says. After struggling for years, Patel eventually connected with <a href="https://www.uchealth.org/provider/rachel-davis-md/">Rachel Davis</a>, a psychiatrist and researcher also at the University of Colorado. Davis suggested that he could be a good candidate for deep brain stimulation as a treatment for his OCD. </p>
<p>“Deep brain stimulation involves the implantation of electrodes in the deeper areas of the brain,” Davis explains. These electrodes then transfer into the brain itself small electrical currents that a doctor and their patient try to tune correctly. As Davis explains, “Basically we’re looking to find the settings where the patient feels that their mood is better, their anxiety is less and they have more energy.”</p>
<p>Deep brain stimulation works well for a lot of patients and has only started to get mainstream attention in the past decade or so, but ideas underlying this treatment are nearly 60 years old. As explained by <a href="https://directory.weill.cornell.edu/person/profile/jjfins">Joseph Fins</a>, a neuroethicist and professor of medicine at Weill Cornell Medical College, part of Cornell University in the US, it all started with a Spanish neuroscientist named Jose Manuel Rodriguez Delgado in 1964. “He put a thing called the stimoceiver, a deep brain stimulator, into the brain of a charging bull. And with an electrical current controlled by radio frequency, he was able to stop the bull in its tracks.”</p>
<p>While this work got Delgado on the front page of The New York Times, it came on the heels of a horrific era of mental health treatment that involved lobotomies, electroshock therapy and many other destructive and deeply unethical interventions. So when researchers began to discover drugs that could help people with mental illness, Fins says “psychosurgery and these types of somatic therapies began to fall out of favor and physicians moved away from more physical interventions.”</p>
<p>As modern neuroscience led to better understanding of how the brain works, and stigma surrounding physical treatments faded, deep brain stimulation got its second chance in the sun. And as technology has improved, researchers like <a href="https://scholar.google.com/citations?user=BD8dNTUAAAAJ&hl=en&oi=ao">Jacinta O'Shea, a neuroscientist</a> at the University of Oxford have begun to study a noninvasive technique for stimulating the brain with electricity, called transcranial magnetic stimulation. </p>
<p>“If you place a ferromagnetic coil on the scalp and pass a rapidly changing electrical current through that coil, it will induce an electric field that passes painlessly through the skull and into the brain tissue underneath,” O'Shea explains. And just as with deep brain stimulation, these electrical fields can help people overcome mental health issues like depression.</p>
<p>Researchers still don’t quite know how deep brain stimulation or transcranial magnetic stimulation work, but with every new treatment, they are learning more about the complicated world of the brain and taking steps toward the treatments of tomorrow.</p>
<p>Listen to the full episode of The Conversation Weekly to find out more. </p>
<p>This episode was produced and written by Katie Flood and Daniel Merino, with sound design by Eloise Stevens. The executive producer was Gemma Ware. Our theme music is by Neeta Sarl. </p>
<p>You can find us on Twitter <a href="https://twitter.com/TC_Audio">@TC_Audio</a>, on Instagram at <a href="https://www.instagram.com/theconversationdotcom/">theconversationdotcom</a> or <a href="mailto:podcast@theconversation.com">via email</a>. You can also sign up to The Conversation’s <a href="https://theconversation.com/newsletter">free daily email here</a>. A transcript of this episode is <a href="https://cdn.theconversation.com/static_files/files/2792/Ep82_Neural_Psychiatry_Transcript.pdf?1694452606">available now</a>.</p>
<p>Listen to The Conversation Weekly via any of the apps listed above, download it directly via our <a href="https://feeds.acast.com/public/shows/60087127b9687759d637bade">RSS feed</a>, or find out <a href="https://theconversation.com/how-to-listen-to-the-conversations-podcasts-154131">how else to listen here</a>.</p><img src="https://counter.theconversation.com/content/195071/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacinta O'Shea has consulted for Welcony Inc and is currently on the Scientific Advisory Board of Plato Science. She receives research funding from the Wellcome Trust/Royal Society and the Academy of Medical Sciences in the U.K.
Joseph Fins receives funding from the U.S. National Institutes of Health BRAIN Initiative, Dana Foundation, Greenwall Foundation, Robert Wood Johnson Foundation, Buster Foundation, NIH CTSC, NIH Eunice Kennedy Shriver National Institute of Child Health, Blythedale Children’s Hospital and from numerous editorial boards. He is also the president of the International Neuroethics Society, Chair-Elect and board member of The Hastings Center and a Trustee Emeritus at Wesleyan University</span></em></p><p class="fine-print"><em><span>Rachel Davis consults for Medtronic, Inc. She receives funding from the U.S. National Institutes of Health.
Moksha Patel has nothing to disclose. </span></em></p>Deep brain stimulation and trasncranial magnetic stimulation treat mental illness by sending electrical currents into parts of the brain. Every new patient provides researchers with a wealth of information. Listen to The Conversation Weekly podcast.Daniel Merino, Associate Science Editor & Co-Host of The Conversation Weekly Podcast, The ConversationGemma Ware, Editor and Co-Host, The Conversation Weekly Podcast, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1861092022-09-28T12:32:58Z2022-09-28T12:32:58ZDeep brain stimulation can be life-altering for OCD sufferers when other treatment options fall short<figure><img src="https://images.theconversation.com/files/486344/original/file-20220923-8064-5j7otz.jpg?ixlib=rb-1.1.0&rect=1161%2C23%2C6826%2C4467&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Deep brain stimulation relies on thin electrodes implanted deep in the brain that deliver electrical currents. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/artificial-intelligence-digital-concept-royalty-free-image/1283240410">Olemedia/E+ via Getty Images</a></span></figcaption></figure><p>Imagine growing up tormented by fears and life-consuming rituals that make no sense to you or those around you. Then imagine the shame of being told by mental health providers that, because you understand that your behaviors are illogical but keep doing them anyway, you must want to stay sick. </p>
<p>One of my patients, Moksha Patel, who is a doctor himself, endured this from childhood until his early 30s. In September 2021, Patel underwent deep brain stimulation surgery, a rare neurosurgical procedure that can be used for severe obsessive-compulsive disorder, or OCD, when it has been resistant to less invasive treatments. </p>
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<p>Patel has consented to this publication of his medical information. He <a href="https://news.cuanschutz.edu/news-stories/ocd-ruled-moksha-patels-life-until-a-rare-surgical-procedure-changed-everything">shares his story publicly</a> to combat stigma and to provide hope for other sufferers that relief is possible. </p>
<p>The term OCD is thrown around casually, often by someone joking about how organized they are: “I’m so OCD.” But true <a href="https://doi.org/10.1176/ajp.153.6.783">obsessive-compulsive disorder is debilitating</a> and leads to <a href="https://doi.org/10.1007/s40263-013-0056-z">significant suffering</a>. </p>
<p>I <a href="https://som.ucdenver.edu/Profiles/Faculty/Profile/13845">lead a team</a> that treats people with OCD using <a href="https://medschool.cuanschutz.edu/psychiatry/PatientCare/obsessive-compulsive-disorder-program">evidence-based approaches</a>. I am also co-director of the <a href="https://medschool.cuanschutz.edu/psychiatry/PatientCare/obsessive-compulsive-disorder-program/reclaim-deep-brain-stimulation-therapy-for-ocd">OCD surgical program</a> at the University of Colorado, Anschutz campus, and UC Health, a nonprofit health care system in Colorado. </p>
<p>Our surgical program is one of the few academic centers in the U.S. that offer deep brain stimulation for the treatment of OCD. My experience and research have given me insight into how a rare procedure can be used in <a href="https://doi.org/10.3389/fpsyt.2021.568932">real-world settings</a> to provide relief to those who suffer from OCD when other less invasive treatments have not been successful.</p>
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<figcaption><span class="caption">Dr. Sabine Wilhelm of Mass General Hospital answers the most commonly searched questions about obsessive-compulsive disorder.</span></figcaption>
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<h2>What does OCD feel like for a sufferer?</h2>
<p>A brain with OCD is primed to detect any signs of potential danger. Many people with OCD <a href="https://iocdf.org/blog/2019/04/22/what-it-feels-like-to-live-with-ocd/">wake up every day with a sense of dread</a> and an expectation of bad things happening. Daily life is overshadowed by ever-present guilt, shame, fear and doubt. As a result, they carry out compulsive and repetitive activities to attempt to forestall disaster and manage the painful emotions. </p>
<p>OCD fears most often involve the things and people that matter the most to the sufferer, such as their values, loved ones or purpose in life. For example, someone who values kindness and compassion might fear that they will offend, betray or somehow hurt the people they care about.</p>
<p>Sometimes what is hardest for someone who suffers with OCD is a recognition that the fears and behaviors are illogical – insight that provides no relief. </p>
<p>And because other people usually don’t understand, those with OCD do their best to hide their illness so they won’t be judged as ridiculous or “crazy,” which often leads to long delays in diagnosis and treatment. This is a painful and lonely life for the approximately <a href="https://www.psychiatrist.com/jcp/ocd/ocd-prevalence-and-gender/">1%-2% of the world population with OCD</a>. </p>
<h2>Current OCD treatment options</h2>
<p>The best initial treatment for OCD is a type of mental health therapy called <a href="https://www.erp4ocd.com/">exposure and response prevention</a>. During these sessions, OCD sufferers are supported in gradually confronting their fears while also limiting the behaviors they have come to associate with providing safety. </p>
<p>For instance, someone with a fear of harming others might start by sitting near a butter knife and work their way up to holding a sharper knife to their therapist’s throat. They either learn that their fear does not play out, or – in the case of fears that cannot be disproved – that they can tolerate their anxiety or distress and move forward even in the absence of certainty. </p>
<p>The primary <a href="https://iocdf.org/about-ocd/ocd-treatment/meds/">medications used to treat OCD</a> are <a href="https://www.fda.gov/drugs/information-drug-class/selective-serotonin-reuptake-inhibitors-ssris-information">serotonin reuptake inhibitors, or SRIs/SSRIs</a>, which are commonly prescribed for treatment of depression and anxiety. But when used for OCD, these medications are typically prescribed at much higher dosages.</p>
<p>Unfortunately, <a href="https://doi.org/10.4088/jcp.v67n0214">OCD is a chronic condition</a> for most; studies show that only 65% of people with OCD respond to standard treatment, which is a combination of therapy and medication, and only about 35% recover completely. About 10% of individuals with OCD <a href="https://doi.org/10.1186/s12888-014-0214-y">remain severely impaired</a>, regardless of how intensively they are treated.</p>
<h2>The potential of deep brain stimulation</h2>
<p>For this small group of individuals with severe and persistent OCD, deep brain stimulation – a procedure that <a href="http://dx.doi.org/10.5498/wjp.v11.i9.659">fewer than 400 people</a> with OCD have undergone worldwide – provides hope. </p>
<p>Patel, an internal medicine doctor, first came to my office in 2019. He is one of 13 patients I’ve worked with to provide deep brain stimulation for OCD and other psychiatric illnesses.</p>
<p>He has suffered with OCD since the age of 4 or 5, with obsessive fears about germs, contamination and social interactions, among other things. He learned to function and succeed by shaping his life around his rituals – for example, by not consuming water or food at work so that he would not need to use public restrooms. </p>
<p>Patel, like many others with OCD, is conscientious, thorough and compassionate, traits that contribute to his success as a physician. However, before deep brain stimulation, most of his life outside of work was occupied by painful, consuming rituals. These included scrubbing himself with harsh chemicals for hours. </p>
<p>He had explored every treatment he could find, seeing 13 mental health providers since high school and participating in years of exposure therapy. He had tried at least 15 different medications, all with little benefit. Then he learned that deep brain stimulation was available at the hospital where we both work. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A neurosurgeon prepares his patient, who is lying down, for deep brain stimulation surgery." src="https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Dr. Steven Ojemann, a CU Anschutz/UCHealth neurosurgeon, preparing Dr. Moksha Patel for deep brain stimulation surgery on Sept. 15, 2021.</span>
<span class="attribution"><span class="source">Radhika Patel</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<h2>How deep brain stimulation works</h2>
<p>Deep brain stimulation requires a neurosurgical procedure to place thin electrodes into deep structures of the brain, specifically a region known as the <a href="https://doi.org/10.1016/j.wneu.2019.01.254">ventral capsule/ventral striatum</a>. These <a href="https://www.youtube.com/watch?v=wYLJGuUt4iI">electrodes deliver electrical currents to the brain</a>. The current is produced by pulse generators in the chest that look much like cardiac pacemakers. They are connected to the electrodes in the brain by wires tunneled beneath the skin.</p>
<p>We researchers do not yet have a precise understanding of exactly how deep brain stimulation works, but we do know that it <a href="https://doi.org/10.1038/nn.3344">normalizes the communication</a> between parts of the brain responsible for taking in information and those responsible for acting on this information. These areas are hyperconnected in people with OCD, leading to a reduced ability to make thoughtful, value-driven decisions and an over-reliance on <a href="https://doi.org/10.1038/s41380-020-01007-8">reflexive or habitual behaviors</a>. And the changes induced by deep brain stimulation correlate with a reduction in OCD symptoms.</p>
<p>This type of neurostimulation is most commonly used to manage symptoms of <a href="https://www.nia.nih.gov/health/parkinsons-disease">Parkinson’s disease</a>, a movement disorder that leads to tremors and body rigidity. OCD is the only psychiatric disorder that currently has approval from the Food and Drug Administration for deep brain stimulation treatment. But deep brain stimulation <a href="https://doi.org/10.3171/2015.3.FOCUS1546">has been investigated</a> in <a href="https://doi.org/10.1016/j.neuroimage.2020.117515">other conditions, including major depression</a>, Tourette syndrome, schizophrenia, substance use disorders, post-traumatic stress disorder and eating disorders. </p>
<p>Deep brain stimulation is a procedure of last resort for patients with OCD. Because of the invasive nature of brain surgery and the potential for <a href="https://doi.org/10.1016/j.neubiorev.2020.01.007">serious adverse effects</a> such as infection or hemorrhage, individuals need to try standard, less invasive treatments first and meet the <a href="https://doi.org/10.3389/fpsyt.2021.706181">criteria for severe and persistent OCD</a>, which have been established based on OCD and brain stimulation research. </p>
<p>But for those who do undergo the procedure for OCD treatment and receive ongoing stimulation, <a href="https://doi.org/10.1038/mp.2008.55">up to 70%</a> have a <a href="http://dx.doi.org/10.5498/wjp.v11.i9.659">good long-term response</a>. “Good” is considered to be a 35% reduction in OCD symptoms based on a <a href="https://doi.org/10.1001/archpsyc.1989.01810110048007">standardized scale for obsessive-compulsive behavior</a> that experts in our field rely on. </p>
<p>This, for example, could mean that someone goes from spending more than eight hours per day on OCD behaviors and not leaving the house at all to spending four hours per day and being able to go to school with significant support. Such progress is remarkable, given how ill these individuals are.</p>
<h2>Barriers and stigma</h2>
<p>There aren’t very many treatment centers anywhere in the world, so patients who need this procedure may have trouble getting to one. Additionally, as our team has described in published research, getting insurance coverage for the procedure is <a href="https://doi.org/10.1038/s41591-022-01879-z">often time-consuming</a> and <a href="https://doi.org/10.3389/fsurg.2021.642503">sometimes prohibitive</a>. </p>
<p>Another barrier is the stigma associated with brain surgery for psychiatric illness. The reasons behind this stigma are complicated, and some factors have historical roots. In the early to mid-1900s, destructive, dangerous and <a href="https://nihrecord.nih.gov/2019/11/01/when-faces-made-case-lobotomy">not very effective brain surgeries such as lobotomies</a> were performed routinely for mental illness without regulation, ethical guidelines or regulatory oversight.</p>
<h2>A way forward</h2>
<p>After I worked with Patel for about a year, including trials of six additional medications and ongoing exposure and response prevention therapy, his symptoms remained severe. I recommended he begin the extensive evaluation process for deep brain stimulation surgery.</p>
<p>Three weeks after his surgery, I turned on electrical stimulation, and we began the intensive programming procedure to determine the optimal settings. This process takes several hours a day over the course of several days, with fine-tuning in the following weeks and months. </p>
<p>Patel recalls that early on, during programming, he experienced a roller coaster of feelings, shifting between “giddiness and sadness.” Most individuals experience gradual improvement over the course of six to 12 months. At first, they feel happier and less anxious, and weeks to months later they experience a decrease in OCD symptoms. </p>
<p>Most commonly, stimulation is constant, 24 hours a day. But the treating psychiatrist may give the patient the ability to turn it off, such as at night if the stimulation causes problems with sleep.</p>
<p>Since surgery, Patel has continued weekly therapy sessions. Research shows that <a href="https://doi.org/10.1017/s0033291714000956">deep brain stimulation is most effective</a> when people continue to engage in exposure and response prevention therapy. Electricity alone will not break years of hard-wired habits, but it can be the catalyst that allows for new neural pathways to be established and new behaviors to be learned. Likewise, most individuals need to continue medication. Though the effects of deep brain stimulation can be remarkable, it is not a cure. </p>
<p>Patel has experienced a 54% reduction in his OCD, according to the <a href="https://doi.org/10.1001/archpsyc.1989.01810110048007">standardized scale</a>. This means that his symptoms decreased from the “extreme OCD” to the “moderate” range. </p>
<p>He can now eat and drink at work and use public restrooms. He has more social connections, seeks less reassurance and spends less time decontaminating himself and his belongings. While sleep was previously his only respite, Patel is now intentional about finding meaningful activities to fill the hours that are no longer occupied by rituals. </p>
<p>Most importantly, he is beginning to feel hopeful that it just might be possible to build a life driven by purpose and intention, rather than by fear.</p><img src="https://counter.theconversation.com/content/186109/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Davis consults for Medtronic, Inc. She receives funding from the NIH . </span></em></p>This rare procedure is offered by only a handful of centers in the US and around the world and should be used only when less invasive treatment options for OCD have been tried.Rachel A. Davis, Associate Professor of Psychiatry and Neurosurgery, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1855772022-08-09T12:17:40Z2022-08-09T12:17:40ZTo break unhealthy habits, stop obsessing over willpower – two behavioral scientists explain why routines matter more than conscious choices<figure><img src="https://images.theconversation.com/files/476775/original/file-20220730-27214-mvt4h8.jpg?ixlib=rb-1.1.0&rect=51%2C17%2C5760%2C3776&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people attribute their coffee drinking to the need to feel more alert, but research shows that habit is just as big a driver behind caffeine consumption.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com.mx/detail/foto/young-woman-sitting-on-park-bench-drinking-imagen-libre-de-derechos/656296993?adppopup=true">Westend61/Getty Images</a></span></figcaption></figure><p>If you’re <a href="https://www.statista.com/statistics/456366/total-us-coffee-per-capita-consumption-by-age-group/#">like many Americans</a>, you probably start your day with a cup of coffee – a morning latte, a shot of espresso or maybe a good ol’ drip brew.</p>
<p>A common explanation among avid coffee drinkers is that we drink coffee to wake ourselves up and alleviate fatigue. </p>
<p>But that story doesn’t completely hold up. After all, the amount of caffeine in a cup of coffee <a href="https://doi.org/10.1016/j.fct.2007.02.020">can vary wildly</a>. Even when ordering the same type of coffee from the same coffee shop, <a href="https://doi.org/10.1093/jat/27.7.520">caffeine levels can double from one drink to the next</a>. And yet, we coffee drinkers don’t seem to notice. </p>
<p>So what else might be driving us in our quest for that morning brew?</p>
<p>That’s one question we set out to answer in our recent research. The answer has far-reaching implications for the way we approach major societal challenges such as diet and climate change.</p>
<p>As <a href="https://scholar.google.com/citations?user=xGaNvJ8AAAAJ&hl=en&oi=ao">behavioral</a> <a href="https://scholar.google.com/citations?user=SlkbsS4AAAAJ&hl=en&oi=ao">scientists</a>, we’ve learned that people often repeat everyday behaviors out of habit. If you regularly drink coffee, you likely do so automatically as part of your habitual routine – not just out of tiredness.</p>
<p>But habit just doesn’t feel like a good explanation – it’s unsatisfying to say that we do something just because it’s what we’re used to doing. Instead, we concoct more compelling explanations, like saying we drink coffee to ease our morning fog. </p>
<p>This reluctance means that we fail to recognize many habits, even as <a href="https://doi.org/10.1037/0022-3514.83.6.1281">they permeate our daily lives</a>. </p>
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<figcaption><span class="caption">Habits are formed in specific environments that provide a cue, or trigger, for the behavior.</span></figcaption>
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<h2>Unpacking what lies behind habits</h2>
<p>To test whether people underestimate the role that habit plays in their life, we asked more than 100 coffee drinkers what they think drives their coffee consumption. They estimated that tiredness was about twice as important as habit in driving them to drink coffee. To benchmark these assumptions against reality, we then tracked these people’s coffee drinking and fatigue over the course of one week.</p>
<p>The actual results starkly diverged from our research participants’ explanations. Yes, they were somewhat more likely to drink coffee when tired – as would be expected – but we found that habit was an equally strong influence. In other words, people wildly overestimated the role of tiredness and underestimated the role of habit. Habits, it seems, aren’t considered much of an explanation. </p>
<p>We then replicated this finding in a second study with a behavior that people might consider a “bad” habit – failing to help in response to a stranger’s request. People still overlooked habit and assumed that their reluctance to proffer help was due to their mood at the time.</p>
<p>The gap between the actual and perceived role of habit in our lives matters. And this gap is key to understanding why people often struggle to change repeated behaviors. If you believe that you drink coffee because you are tired, then you might try to reduce coffee drinking by going to bed early. But ultimately you’d be barking up the wrong tree – your habit would still be there in the morning. </p>
<h2>Why habits are surprisingly difficult to change</h2>
<p>The reason that habits can be so difficult to overcome is that they are not fully under our control. Of course, most of us can control a single instance of a habit, such as by refusing a cup of coffee this time or taking the time to offer directions to a lost tourist. We exert willpower and just push through. But consistently reining in a habit is fiendishly difficult. </p>
<p>To illustrate, imagine you had to avoid saying words that contain the letter “I” for the next five seconds. Pretty simple, right? But now imagine if you had to maintain this rule for a whole week. We habitually use many words that contain “I.” Suddenly, the required 24/7 monitoring turns this simple task into a far more onerous one. </p>
<p>We make a similar error when we try to control unwanted habits and form new, desirable ones. Most of us can achieve this in the short run – think about your enthusiasm when starting a new diet or workout regimen. But we inevitably get distracted, tired or just plain busy. When that happens, your old habit is <a href="https://doi.org/10.1177/1745691621994226">still there to guide your behavior</a>, and you end up back where you started. And if you fail to recognize the role of habit, then you’ll keep overlooking better strategies that effectively target habits.</p>
<p>The flip side is also true: We don’t recognize the benefits of our good habits. One study found that on days when people strongly intended to exercise, those with weak and strong exercise habits got similar amounts of physical activity. On days when intentions were weaker, however, those with <a href="https://doi.org/10.1123/jsep.2013-0173">strong habits were more active</a>. Thus, strong habits keep behavior on track even as intentions ebb and flow.</p>
<h2>It’s not just willpower</h2>
<p>American culture is partly responsible for the tendency to overlook habits. Compared with residents of other developed nations, Americans are more likely to say that <a href="https://www.pewresearch.org/wp-content/uploads/sites/2/2014/10/Pew-Research-Center-Inequality-Report-FINAL-October-17-2014.pdf">they control their success in life</a>.</p>
<p>Accordingly, when asked what stops them from making healthy lifestyle changes, Americans commonly cite <a href="https://www.apa.org/news/press/releases/stress/2010/key-findings#">a lack of willpower</a>. Granted, willpower is useful in the short term, as we muster the motivation to, for example, sign up for a gym membership or start a diet. </p>
<p>But research shows that, surprisingly, people who are more successful at achieving long-term goals <a href="https://doi.org/10.1037/a0026545">exert – if anything – less willpower</a> in their day-to-day lives. This makes sense: As explained above, over time, willpower fades and habits prevail. </p>
<p>If the answer isn’t willpower, then what is the key to controlling habits? </p>
<p>Changing habits begins with the environments that support them. Research shows that leveraging the cues that trigger habits in the first place can be incredibly effective. For example, reducing the visibility of cigarette packs in stores <a href="https://doi.org/10.1136/tobaccocontrol-2017-053996">has curbed cigarette purchases</a>. </p>
<p>Another path to habit change involves friction: in other words, making it difficult to act on undesirable habits and easy to act on desirable ones. For example, one study found that <a href="https://doi.org/10.1901/jaba.1993.26-247">recycling increased</a> after recycle bins were placed right next to trash cans – which people were already using – versus just 12 feet away. </p>
<p>Effectively changing behavior starts with recognizing that a great deal of behavior is habitual. Habits keep us repeating unwanted behaviors but also desirable ones, even if just enjoying a good-tasting morning brew.</p><img src="https://counter.theconversation.com/content/185577/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Wood receives research funding from National Institute on Aging, Centers for Disease Control and Prevention. </span></em></p><p class="fine-print"><em><span>Asaf Mazar does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Understanding and changing the environment in which habits form is a critical step when it comes to breaking unwanted behaviors and forming healthy ones.Asaf Mazar, Postdoctoral fellow in Behavioral Science, University of PennsylvaniaWendy Wood, Provost Professor Emeritus of Psychology and Business, USC Dornsife College of Letters, Arts and SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1725252021-11-30T10:09:21Z2021-11-30T10:09:21ZHow uncertainty can impair our ability to make rational decisions – new research<figure><img src="https://images.theconversation.com/files/434446/original/file-20211129-25-1uzycqz.jpg?ixlib=rb-1.1.0&rect=368%2C44%2C4551%2C3179&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When times are uncertain, we can fail to be flexible.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-nose-ring-pink-sticky-124672096">jefftakespics2/Shutterstock</a></span></figcaption></figure><p>We make decisions every day, many of which are so straightforward that we hardly notice we are making them. But we tend to struggle when faced with decisions that have uncertain outcomes, such as during the pandemic. Cognitive scientists have long been interested in understanding how people make such uncertain decisions. Now our <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786681">new research</a>, published in the journal JAMA Network Open, gives a clue.</p>
<p>Scientists typically test decision-making under uncertainty using “probabilistic tasks”, in which study participants can choose from two or more options, each with a specific probability of providing a reward (usually points or money). This could be a game, for example, in which you have to choose between a picture of an apple or a banana on a computer screen. The apple might be programmed to give you points 80% of the time while the banana will do so 20% of the time, but during the game the probabilities can change. You would not be aware of the probabilities at any given time, however – leading to uncertainty. Your task would be to find out which option is more rewarding.</p>
<p>Humans generally use two decision-making strategies when faced with uncertainty: exploitation and exploration. Exploitation involves frequently choosing options that are familiar and provide a higher certainty of reward. Exploration involves trying out choices that are unfamiliar. In an uncertain and changing environment, it is thought that the best strategy is to <a href="https://www.nature.com/articles/npp2017108">flexibly alternate</a> between exploration and exploitation. </p>
<p>Whether people explore or exploit depends on the situation at hand. When under <a href="https://europepmc.org/article/ppr/ppr376314">time pressure</a>, people are more likely to repeat old choices and explore less. </p>
<h2>Obsessive-compulsive disorder</h2>
<p>A common symptom of many psychiatric disorders is difficulty in coping with uncertainty. People suffering from obsessive-compulsive disorder (OCD), in particular, feel incredibly uncertain about their thoughts, feelings and actions, and may feel anxious. They may feel doubtful over whether they counted the number of tiles accurately, or whether they scrubbed their hands thoroughly enough.</p>
<p>In our <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786681">study</a>, we demonstrate that people with OCD struggle to make decisions when they are uncertain. We asked 50 teenagers with OCD and 53 teenagers without OCD to complete a probabilistic task, in which the probabilities associated with each option would reverse halfway through the task (for example the apple picture would go from giving a reward 80% of the time to 20% of the time). The ideal strategy would be to exploit the more rewarding choice early on (apple), but then engage in exploration (pick banana) once you’ve noticed a shift in how often points are offered.</p>
<p>Teenagers with OCD did not do this, however. Across the task, they displayed a great deal of exploration of choices. They showed a tendency to switch choices and select the less rewarding choice more often than teenagers without OCD. Fascinatingly, when teenagers with OCD performed another task which was not probabilistic and didn’t trigger uncertainty, they showed no problems with decision-making. </p>
<p>Uncertainty caused by the probabilistic task may have caused teenagers with OCD to doubt their decisions and feel the need to “check” the less rewarding choice frequently. This exploration could be a strategy for them to try to <a href="https://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1005440">seek out information</a> until they feel certain. Intolerance of uncertainty is a plausible reason for why people with OCD feel compelled to check items like locks, stoves and switches in daily life. </p>
<p>The results also suggest that many people may start to explore in this way if they are <a href="https://link.springer.com/article/10.3758/s13423-019-01653-2">feeling uncertain enough</a>. </p>
<h2>Pandemic uncertainty</h2>
<p>The COVID-19 pandemic has caused a great deal of uncertainty for everyone, which in turn seems to have increased our tendency for exploration in the form of information-seeking. A <a href="https://journals.sagepub.com/doi/full/10.1177/1075547020959818">study has shown</a> that perceived uncertainty has led to people seeking more information about COVID via social networking apps and online news media. </p>
<p>On the one hand, this has led to more <a href="https://www.liebertpub.com/doi/full/10.1089/cyber.2020.0250">preventative actions</a>, such as increased hand washing and mask wearing, which can reduce uncertainty and keep people safe. On the other hand, this information-seeking may not be entirely beneficial. A <a href="https://www.nature.com/articles/s41398-021-01410-x">recent study</a> has shown that since the onset of the pandemic, otherwise healthy people are reporting more obsessive-compulsive symptoms, such as constantly checking for new information to reduce feelings of pandemic-induced uncertainty.</p>
<figure class="align-center ">
<img alt="Image of an MRI brain scan." src="https://images.theconversation.com/files/434398/original/file-20211129-21-11ww55u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434398/original/file-20211129-21-11ww55u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434398/original/file-20211129-21-11ww55u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434398/original/file-20211129-21-11ww55u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434398/original/file-20211129-21-11ww55u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434398/original/file-20211129-21-11ww55u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434398/original/file-20211129-21-11ww55u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stress from exploration can change the brain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/brain-scan-273127421">Semnic</a></span>
</figcaption>
</figure>
<p>Excessive information-seeking during this period can lead to high levels of stress. We know from previous research that it can eventually lead to burnout and <a href="https://www.sciencedirect.com/science/article/pii/S030645732030933X">avoidance of information</a> altogether, leaving people less informed about government guidelines, safety measures and COVID-19 treatment advances. </p>
<p>Persistent stress from overexposure to distressing news may also <a href="https://theconversation.com/how-chronic-stress-changes-the-brain-and-what-you-can-do-to-reverse-the-damage-133194">cause changes</a> in key brain areas such as the ventromedial prefrontal cortex and hippocampus, which are responsible for memory and cognition. This can in turn result in reduced rational decision-making, leading us to rely more on emotions. This could make us susceptible to believing misinformation and engaging in irrational behaviours, such as hoarding toilet paper.</p>
<p>Luckily, there are <a href="https://theconversation.com/learning-to-cope-with-uncertainty-during-covid-19-151420">ways to combat</a> pandemic uncertainty by trusting some of the information you’ve already gathered and that seems consistent over time, such as the benefits of masks and vaccines. If you are finding it difficult to cope without frequently checking the news and social media for reassurance, <a href="https://www.healthline.com/health-news/doomscrolling-during-covid-19-how-you-can-avoid-it#Staying-informed-without-the-doom">experts recommend</a> setting a timer on social media use, logging out of accounts temporarily, and <a href="https://theconversation.com/doomscrolling-covid-news-takes-an-emotional-toll-heres-how-to-make-your-social-media-a-happier-place-170342">seeking out</a> more positive, non-pandemic related content online. </p>
<p>There are even evidence-based methods to improving your decision-making under uncertainty, including playing games designed to <a href="https://theconversation.com/coronavirus-the-pandemic-is-changing-our-brains-here-are-the-remedies-144451">train your brain</a>, getting <a href="https://theconversation.com/six-ways-to-reboot-your-brain-after-a-hard-year-of-covid-19-according-to-science-151332">good sleep and nutrition</a>, and having social support.</p><img src="https://counter.theconversation.com/content/172525/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Jacquelyn Sahakian consults for Cambridge Cognition. Dr Sahakian’s research is funded by the Wellcome Trust, the Lundbeck Foundation and the Leverhulme Trust and is conducted within the NIHR MedTech and in vitro diagnostic Cooperative (MIC) and the NIHR Cambridge Biomedical Research Centre (BRC) Mental Health and Neurodegeneration Themes. </span></em></p><p class="fine-print"><em><span>Aleya Aziz Marzuki received funding as a research assistant and PhD student from a Wellcome Trust Grant awarded to Professor Trevor Robbins (104631/Z/14/Z/) and was the recipient of a grant from the G C Grindley Fund. </span></em></p>High levels of uncertainty can make us obsessive compulsive, causing physical changes in the brain.Barbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeAleya Aziz Marzuki, PhD Candidate in Cognitive Neuroscience, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1632842021-06-23T15:40:18Z2021-06-23T15:40:18ZIQ tests can’t measure it, but ‘cognitive flexibility’ is key to learning and creativity<figure><img src="https://images.theconversation.com/files/407965/original/file-20210623-15979-1ydf8cp.jpg?ixlib=rb-1.1.0&rect=0%2C12%2C2048%2C1578&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Einstein thought imagination was crucial.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/43531522@N00/17083401791">Robert and Talbot Trudeau/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>IQ is often hailed as a crucial driver of success, particularly in fields such as science, innovation and technology. In fact, many people have an <a href="https://www.businessinsider.com/the-40-smartest-people-of-all-time-2015-2?r=US&IR=T">endless fascination</a> with the IQ scores of famous people. But the truth is that some of the greatest achievements by our species have <a href="https://www.forbes.com/sites/matthewfrancis/2018/05/08/no-scientists-are-not-smarter-than-non-scientists/?sh=6e16a5d128d9">primarily relied on</a> qualities such as creativity, imagination, curiosity and empathy. </p>
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<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/iq-tests-cant-measure-it-but-cognitive-flexibility-is-key-to-learning-and-creativity-163284&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p><em>You can listen to more articles from The Conversation, narrated by Noa, <a href="https://theconversation.com/uk/topics/audio-narrated-99682">here</a>.</em></p>
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<p>Many of these traits are embedded in what scientists call “cognitive flexibility” – a skill that enables us to switch between different concepts, or to adapt behaviour to achieve goals in a novel or changing environment. It is essentially about learning to learn and being able to be flexible about the way you learn. This includes changing strategies for optimal decision-making. In our ongoing research, we are trying to work out how people can best boost their cognitive flexibility.</p>
<p>Cognitive flexibility provides us with the ability to see that what we are doing is not leading to success and to make the appropriate changes to achieve it. If you normally take the same route to work, but there are now roadworks on your usual route, what do you do? Some people remain rigid and stick to the original plan, despite the delay. More flexible people adapt to the unexpected event and problem-solve to find a solution.</p>
<p>Cognitive flexibility may have affected how people coped with the pandemic lockdowns, which produced new challenges around work and schooling. Some of us found it easier than others to adapt our routines to do many activities from home. Such flexible people may also have changed these routines from time to time, trying to find better and more varied ways of going about their day. Others, however, struggled and ultimately became more rigid in their thinking. They stuck to the same routine activities, with little flexibility or change. </p>
<h2>Huge advantages</h2>
<p>Flexible thinking is key to creativity – in other words, the ability to think of new ideas, make novel connections between ideas, and make new inventions. It also supports academic and work skills such as problem solving. That said, unlike working memory – how much you can remember at a certain time – it is largely independent of IQ, or “<a href="https://journals.sagepub.com/doi/pdf/10.1111/j.1467-9280.2006.01681.x?casa_token=Yq62iS_OEOcAAAAA:9sUHau1I_ByZ3GJ8s7blJYVmFRAcdsqMTtPjLKrzh5Vo3Gdbz3ZgxpM_LHUbnVqEdhkFwIL5MdNygg">crystallised intelligence</a>”. For example, many visual artists may be of average intelligence, but highly creative and have produced masterpieces. </p>
<p>Contrary to many people’s beliefs, creativity is also important in science and innovation. For example, we have discovered that entrepreneurs who have created multiple companies <a href="https://www.nature.com/articles/456168a">are more cognitively flexible</a> than managers of a similar age and IQ.</p>
<p>So does cognitive flexibility make people smarter in a way that isn’t always captured on IQ tests? We know that it leads to better “<a href="https://dictionary.apa.org/cold-cognition">cold cognition</a>”, which is non-emotional or “rational” thinking, throughout the lifespan. For example, for children it leads to <a href="https://pubmed.ncbi.nlm.nih.gov/24959155">better reading abilities</a> and <a href="https://www.tandfonline.com/doi/abs/10.1080/00220671.1971.10884185">better school performance</a>. </p>
<p>It <a href="https://www.sciencedirect.com/science/article/pii/S0191886919300285">can also help protect</a> against a number of biases, such as confirmation bias. That’s because people who are cognitively flexible are better at recognising potential faults in themselves and using strategies to overcome these faults. </p>
<p>Cognitive flexibility is also associated with higher resilience to <a href="https://pubmed.ncbi.nlm.nih.gov/21432680/">negative life events</a>, as well as <a href="https://pubmed.ncbi.nlm.nih.gov/20359355/">better quality of life</a> in older individuals. It can even be beneficial in emotional and social cognition: studies have shown that cognitive flexibility has a strong link to the ability <a href="https://www.tandfonline.com/doi/pdf/10.1080/15248372.2014.888350?casa_token=NkwyJ_idHqMAAAAA:cZPvD81u_5EGnecSvpHjfCVvg139zdLN06-qDIEa15N7XyjO2V8fEfnrmHM7TPguONR3xj04H-ZI">to understand the emotions</a>, thoughts and intentions of others. </p>
<p>The opposite of cognitive flexibility is cognitive rigidity, which is found in a number of mental health disorders including <a href="https://www.biologicalpsychiatryjournal.com/article/S0006-3223(16)32670-1/fulltext">obsessive-compulsive disorder</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/17825802/">major depressive disorder</a> and <a href="https://journals.sagepub.com/doi/abs/10.1177/0004867417708610?journalCode=anpa">autism spectrum disorder</a>.</p>
<p>Neuroimaging studies have shown that cognitive flexibility <a href="https://jnnp.bmj.com/content/jnnp/early/2020/10/30/jnnp-2020-324104.full.pdf">is dependent on</a> a network of frontal and “striatal” brain regions. The frontal regions are associated with higher cognitive processes such as decision-making and problem solving. The striatal regions are instead linked with reward and motivation. </p>
<figure class="align-center ">
<img alt="Image of brain scans." src="https://images.theconversation.com/files/407909/original/file-20210623-15-l9bnm4.jpg?ixlib=rb-1.1.0&rect=53%2C0%2C6000%2C3970&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/407909/original/file-20210623-15-l9bnm4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/407909/original/file-20210623-15-l9bnm4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/407909/original/file-20210623-15-l9bnm4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/407909/original/file-20210623-15-l9bnm4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/407909/original/file-20210623-15-l9bnm4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/407909/original/file-20210623-15-l9bnm4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some people have more flexible brains.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pet-ct-scan-human-brain-axial-1410637847">Utthapon wiratepsupon/Shutterstock</a></span>
</figcaption>
</figure>
<p>There are a number of ways to objectively assess people’s cognitive flexibility, including the <a href="https://www.tandfonline.com/doi/abs/10.1080/00221309.1948.9918159">Wisconsin Card Sorting Test</a> and the <a href="https://www.cambridgecognition.com/cantab/cognitive-tests/executive-function/intra-extra-dimensional-set-shift-ied/">CANTAB Intra-Extra Dimensional Set Shift Task</a>.</p>
<h2>Boosting flexibility</h2>
<p>The good news is that it seems you can train cognitive flexibility. Cognitive behavioural therapy (CBT), for example, is an evidence-based psychological therapy which <a href="https://www.nature.com/articles/npp2011183">helps people change</a> their patterns of thoughts and behaviour. For example, a person with depression who has not been contacted by a friend in a week may attribute this to the friend no longer liking them. In CBT, the goal is to reconstruct their thinking to consider more flexible options, such as the friend being busy or unable to contact them.</p>
<p><a href="https://www.jneurosci.org/content/jneuro/37/35/8412.full.pdf">Structure learning</a> – the ability to extract information about the structure of a complex environment and decipher initially incomprehensible streams of sensory information –
is another potential way forward. We know that this type of learning involves similar frontal and striatal brain regions as cognitive flexibility. </p>
<p>In a collaboration between the University of Cambridge and Nanyang Technological University, we are currently working on a “real world” experiment to determine whether structural learning can actually lead to improved cognitive flexibility.</p>
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<p>Studies have shown the <a href="https://prc.springeropen.com/articles/10.1186/s41155-017-0069-5">benefits of training</a> cognitive flexibility, for example in children with autism. After training cognitive flexibility, the children showed not only improved performance on cognitive tasks, but also improved social interaction and communication. In addition, cognitive flexibility training has been shown to be <a href="https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01040/full#h5">beneficial for children</a> without autism and in <a href="https://www.frontiersin.org/articles/10.3389/fnhum.2017.00529/full">older adults</a>.</p>
<p>As we come out of the pandemic, we will need to ensure that in teaching and training new skills, people also learn to be cognitively flexible in their thinking. This will provide them with greater resilience and wellbeing <a href="https://twitter.com/britishacademy_/status/1395752200631169028">in the future</a>. </p>
<p>Cognitive flexibility is essential for <a href="https://www.nature.com/articles/4551057a">society to flourish</a>. It can help maximise the potential of individuals to create innovative ideas and creative inventions. Ultimately, it is such qualities we need to solve the big challenges of today, including global warming, preservation of the natural world, clean and sustainable energy and food security.</p>
<p><em>Professors <a href="https://www.neuroscience.cam.ac.uk/directory/profile.php?Trevor">Trevor Robbins</a>, <a href="https://www.ntu.edu.sg/cradle/our-people/annabel-chen-shen-hsing">Annabel Chen</a> and <a href="https://www.neuroscience.cam.ac.uk/directory/profile.php?zkourtzi">Zoe Kourtzi</a> also contributed to this article.</em></p><img src="https://counter.theconversation.com/content/163284/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Jacquelyn Sahakian receives funding from the Wellcome Trust, the Leverhulme Foundation and the Lundbeck Foundation. Her research is conducted within the NIHR MedTech and In vitro diagnostic Co-operative (MIC) and the NIHR Cambridge Biomedical Research Centre (BRC) Mental Health and Neurodegeneration Themes. She consults for Cambridge Cognition.
The University of Cambridge and Nanyang Technological University Centre for Lifelong Learning and Individualised Cognition (CLIC) research project is funded by the National Research Foundation, Prime Minister's Office, Singapore under its Campus for Research Excellence and Technological Enterprise (CREATE) programme.</span></em></p><p class="fine-print"><em><span>Christelle Langley is funded by the Wellcome Trust.</span></em></p><p class="fine-print"><em><span>Victoria Leong receives funding from the Ministry of Education, Singapore and the Centre for Lifelong Learning and Individualised Cognition (CLIC). CLIC is supported by the National Research Foundation, Prime Minister’s Office, Singapore under its Campus for Research Excellence and Technological Enterprise (CREATE) programme.</span></em></p>Are you good at changing perspectives? If so, it may benefit you in more ways than you imagine.Barbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeChristelle Langley, Postdoctoral Research Associate, Cognitive Neuroscience, University of CambridgeVictoria Leong, Assistant Professor of Psychology, Nanyang Technological UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579612021-04-27T06:24:25Z2021-04-27T06:24:25ZNo, OCD in a pandemic doesn’t necessarily get worse with all that extra hand washing<figure><img src="https://images.theconversation.com/files/397230/original/file-20210427-19-9ne5lv.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7951%2C5304&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>At the beginning of the COVID-19 pandemic, we were concerned infection control measures such as extra hand washing and social distancing <a href="https://time.com/5808278/coronavirus-anxiety/">might compound the distress</a> of people living with obsessive-compulsive disorder (OCD). </p>
<p>Early <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151248/">anecdotal evidence</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151537/">case studies</a> reported an apparent increase in OCD relapse rates and symptom severity. </p>
<p>But a year on, we’re learning this is not necessarily the case, and research is giving us a more nuanced understanding of what it’s like to have OCD during a pandemic.</p>
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Read more:
<a href="https://theconversation.com/hoarding-stockpiling-panic-buying-whats-normal-behavior-in-an-abnormal-time-149422">Hoarding, stockpiling, panic buying: What's normal behavior in an abnormal time?</a>
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<h2>What is OCD?</h2>
<p>OCD is a common and disabling condition, affecting roughly <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4363.0%7E2014-15%7EMain%20Features%7EMental,%20behavioural%20and%20cognitive%20conditions%7E36">1.2% of Australians</a>. </p>
<p>It’s <a href="https://beyondocd.org/information-for-individuals/clinical-definition-of-ocd">characterised by</a> obsessions (repetitive intrusive thoughts) and compulsions (physical actions or mental rituals) that attempt to quell these preoccupations. </p>
<p>There are several <a href="https://www.sciencedirect.com/science/article/pii/S0165178116302530">subtypes of OCD</a>, including: </p>
<ul>
<li><p>contamination: characterised by obsessions and compulsions centred around washing, cleaning and concerns around personal hygiene and health</p></li>
<li><p>overresponsibility: encompassing pathological doubt, concerns over unintentional harm to others or oneself, and persistent urges to check things</p></li>
<li><p>symmetry: obsessions about things feeling “just right” (for example, uniform and/or symmetrical), resulting in ritualistic behaviours including counting and ordering</p></li>
<li><p>taboo: characterised by unwanted intrusive thoughts that are often violent, sexual or religious in nature.</p></li>
</ul>
<p>Although we don’t fully understand what causes OCD, research points to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4515165/">abnormal activity of specific brain networks</a>, including a network called the cortico-striatal-thalamo-cortical loop. </p>
<p>This network connects key emotional, cognitive and motor hubs in the brain, and it’s particularly important for higher-order cognitive tasks such as <a href="https://www.jneurosci.org/content/38/19/4490.short">thinking flexibly</a>.</p>
<h2>No, people with OCD aren’t ‘quirky’</h2>
<p>There are several <a href="https://iocdf.org/wp-content/uploads/2014/10/OCDMyth-Handout-092313.pdf">prevailing stereotypes</a> about what it means to live with OCD, such as a belief people with the disorder are just a bit quirky, overly particular, “neat freaks” or “germ-phobic”. </p>
<p>Such ideas are frequently promulgated in popular culture. For example, in 2018 Khloe Kardashian promoted her “KHLO-C-D” branding for an online miniseries in which she gave tips on home organisation and cleanliness. The campaign <a href="https://metro.co.uk/2018/03/13/khloe-kardashians-khlo-c-d-harmful-7383999/">was widely criticised</a>.</p>
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<p>While contamination fears and an affinity for symmetry are better recognised in the community (perhaps owing to portrayals in TV and film), the “taboo” and “overresponsibility” dimensions of OCD are far less understood and are therefore <a href="https://www.sciencedirect.com/science/article/pii/S2211364916301579">subject to higher levels of stigma</a>. </p>
<h2>Are we all OCD now?</h2>
<p>The global response to COVID-19 has <a href="https://theconversation.com/are-we-all-ocd-now-coronavirus-fears-blur-the-line-between-obsessive-compulsive-and-safety-amid-a-dangerous-pandemic-140205">blurred the line between</a> pathological behaviours and adaptive health and safety measures. </p>
<p>Behaviours that were previously linked to psychiatric illnesses, such as repetitive washing and sanitising rituals, are now encouraged (at least to some extent) by health authorities.</p>
<p>While infection control directives such as social distancing and hand hygiene play an essential role in our fight against the virus, they take a psychological toll too. </p>
<p>The pandemic has had <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00589-w?fbclid=IwAR1IsBbTX9f8g1bMRjVR2hoscN6QQEGuPK0IQNaqBht80gi0hQ_9KtuAXTA">a profound effect on mental health</a> due to increased stress and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300745/">lifestyle changes</a>. Indeed, scientists have recently proposed a condition called “<a href="https://link.springer.com/article/10.1007/s11920-021-01226-y">COVID-19 stress syndrome</a>”. Some of the symptoms significantly overlap with anxiety disorders and OCD. </p>
<p>While we don’t all have OCD now, it’s unquestionable our collective behaviour has changed in ways that make the distinction between “normal” and “pathological” much more complex.</p>
<p>In this light, the International College of Obsessive–Compulsive Spectrum Disorders <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152877/">has highlighted</a> the unique challenges the pandemic poses for accurately diagnosing OCD. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/you-cant-be-a-little-bit-ocd-but-your-everyday-obsessions-can-help-end-the-conditions-stigma-49265">You can't be 'a little bit OCD' but your everyday obsessions can help end the condition's stigma</a>
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<h2>Living with OCD in a pandemic</h2>
<p>Having a pre-existing mental health condition appears to be the single <a href="https://bmjopen.bmj.com/content/bmjopen/10/12/e043805.full.pdf">most influential predictor of high stress levels</a> during COVID-19. </p>
<p>However, recent evidence from well-controlled studies doesn’t find compelling evidence that people with OCD have been affected by COVID-19 to a greater extent than those with other psychological conditions (such as depression or general anxiety).</p>
<p>One study <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834974/">published in January</a> compared OCD severity in a large group before and during the pandemic. It found the stress induced by COVID-19 increased measures of mental distress across all OCD symptom dimensions (not only those directly related to a public health crisis).</p>
<p>The authors suggested the increase in OCD symptom severity was likely a “non-specific stress-related response”. In other words, it’s the general stress of the pandemic that has worsened OCD in some cases; not the increased focus on infection control.</p>
<figure class="align-center ">
<img alt="A woman sitting on the couch, appears pensive or unhappy." src="https://images.theconversation.com/files/397279/original/file-20210427-23-1d9pkpv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/397279/original/file-20210427-23-1d9pkpv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/397279/original/file-20210427-23-1d9pkpv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/397279/original/file-20210427-23-1d9pkpv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/397279/original/file-20210427-23-1d9pkpv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/397279/original/file-20210427-23-1d9pkpv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/397279/original/file-20210427-23-1d9pkpv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Having a pre-existing mental health condition is the biggest risk factor for having high stress levels during the pandemic.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Another <a href="https://journals.lww.com/jonmd/Citation/2021/04000/Impact_of_the_COVID_19_Pandemic_on_the_Short_Term.8.aspx">recent study</a> found the pandemic didn’t lessen the benefits of treatment in a large outpatient group with OCD in India. </p>
<p>Interestingly, the researchers from this study also found prior incomplete disease remission (cases of OCD that persisted even with treatment) and general stress were the best predictors of OCD relapse during the pandemic, rather than “COVID-specific” stress, per se.</p>
<h2>After the pandemic</h2>
<p>These findings don’t suggest there’s a specific vulnerability to COVID-related stress for people with OCD. </p>
<p>But it’s worth noting cognitive inflexibility, <a href="https://www.sciencedirect.com/science/article/pii/S0306452216303359">a symptom often seen in OCD</a>, may make it more difficult for people with the disorder to “unlearn” temporary public health directives.</p>
<p>So it’s important we continue to monitor the effects of COVID-related stress on OCD and similar disorders, particularly as we slowly transition from the pandemic.</p>
<p>There’s much we can learn from the study of OCD during COVID-19. Most notably, it appears an “intuitive” understanding of the disorder doesn’t sufficiently capture the breadth of individual OCD experiences. </p>
<p>A deeper understanding of the variability of OCD presentations, and a move away from stereotyped perceptions, may encourage more people to openly discuss their own OCD experience and seek treatment.</p>
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<strong>
Read more:
<a href="https://theconversation.com/my-skins-dry-with-all-this-hand-washing-what-can-i-do-134146">My skin's dry with all this hand washing. What can I do?</a>
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<h2>Need support?</h2>
<p>If you live in Australia, call Lifeline (13 11 14), Kids Helpline (1800 551 800) or BeyondBlue (1800 512 348). Alternatively, “<a href="https://www.mentalhealthonline.org.au/pages/about-the-ocd-stop-program">OCD STOP!</a>” is a free online program designed to help you better understand and manage OCD.</p>
<p>If you simply want to learn more about OCD, online resources are available at <a href="https://www.sane.org/information-stories/facts-and-guides/obsessive-compulsive-disorder">SANE Australia</a> and <a href="https://www.beyondblue.org.au/the-facts/anxiety/types-of-anxiety/ocd">Beyond Blue</a>.</p><img src="https://counter.theconversation.com/content/157961/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carey Wilson receives funding from the Australian Government Research Training Program Scholarship.</span></em></p><p class="fine-print"><em><span>Thibault Renoir receives funding from the National Health and Medical Research Council (NHMRC) and Australian Research Council (ARC)</span></em></p>Early reports suggested an apparent increase in OCD relapse rates and symptom severity during the pandemic. But a year on, we’re learning this may not be the case.Carey Wilson, PhD Candidate, The University of MelbourneThibault Renoir, Head of Genes Environment and Behaviour Laboratory, Florey Institute of Neuroscience and Mental HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1556082021-02-24T15:32:00Z2021-02-24T15:32:00ZCoronavirus: the price of global pandemic responses has been to make many other diseases worse<p>We are living through an age of untold suffering. Over 500,000 people have died from coronavirus in the <a href="https://www.bbc.com/news/world-us-canada-56159756">US alone</a>, <a href="https://coronavirus.data.gov.uk/details/deaths">over 120,000 in the UK</a>, and over <a href="https://www.theguardian.com/world/2021/jan/15/global-coronavirus-death-toll-reaches-2-million-people">two million worldwide</a>. With COVID-19 dominating the news cycle, you would be forgiven for forgetting that other diseases still exist. And yet we know full well that diseases don’t stop just because one is hogging all the limelight. </p>
<p>There have been plenty of reports on the troubling cost of the pandemic and associated lockdowns or shelter-in-place orders on people’s mental health. For example, it has had a profound effect on those living with obsessive-compulsive disorder. Studies from Europe show that between a <a href="https://www.theguardian.com/australia-news/2021/feb/21/i-could-physically-feel-the-germs-on-me-how-covid-is-a-double-edged-sword-for-those-with-ocd">third and half of those suffering from OCD</a> had their symptoms worsen during the pandemic. </p>
<p>Young adults seem to have been particularly affected by the emotional burdens of isolation and insecurity. In a recent survey, conducted by the Centers for Disease Control and Prevention in the US, <a href="https://abcnews.go.com/Health/pandemics-mental-health-burden-heaviest-young-adults/story?id=75811308">63% of 18-to-24-year-olds</a> reported symptoms of anxiety or depression, with 25% reporting increased substance use to deal with stress, and 25% saying they’d seriously considered suicide.</p>
<p>Crucially, these issues won’t abate as soon as the pandemic is over. Even when the crisis recedes, Dr Shekar Saxena of the Harvard School of Public Health suggests that <a href="https://abcnews.go.com/Health/pandemics-mental-health-burden-heaviest-young-adults/story?id=75811308">10% of these young people</a> will have to live with the long-lasting effects of the mental illnesses they are currently enduring. </p>
<p>The damage done by the pandemic to mental health has already attracted well-deserved attention. It has highlighted the importance of looking beyond coronavirus deaths to assess the success of global pandemic responses. Cancer tells a similar, and equally distressing, story.</p>
<h2>Cancer care in the pandemic</h2>
<p>Throughout 2020, hospitals across the <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00022-X/fulltext">UK</a>, <a href="https://www.nature.com/articles/s43018-020-0074-y">US</a> and <a href="https://www.france24.com/en/20200515-virus-could-cause-28-mn-cancelled-surgeries-globally-study">Europe</a> cancelled or postponed urgent cancer operations because they could not cope with the rising number of desperately ill coronavirus patients. Determining cancer prognosis <a href="https://www.iqvia.com/blogs/2020/07/the-impact-of-covid19-on-cancer-treatment-across-the-eu5-countries">is complex</a>, but early evidence suggests that even a four-week delay in treatment can raise the risk of death by <a href="https://www.theguardian.com/society/2020/nov/04/four-week-cancer-treatment-delay-raises-death-risk-study-nhs-covid">up to 10%</a>.</p>
<p>The danger is not just physical, but psychological too. Despite these distressing figures of cancellations and waiting times, we don’t yet know much about the emotional toll these delays will have on people living with cancer today. Stories are, however, starting to emerge. One man, diagnosed with stage-4 bowel cancer in June 2020, had his December surgery postponed, and then <a href="http://theguardian.com/world/2021/jan/31/patients-in-limbo-after-cancelled-cancer-surgery-as-covid-delays-nhs-care">“cancelled indefinitely”</a>.</p>
<p>Even in the 19th century, doctors and patients alike were acutely aware of the importance of timely treatment. As I argue in my book, <a href="https://global.oup.com/academic/product/the-cancer-problem-9780198866145?cc=gb&lang=en&">The Cancer Problem</a>, the “do not delay” principle in cancer treatment has its origins in the early 1800s. Surgeons implored cancer sufferers to seek their advice as soon as they had identified any unexpected lumps or bumps. And in their writings, patients expressed extreme distress at waiting for a diagnosis or cure. </p>
<figure class="align-center ">
<img alt="Engraving with two views of a Dutch woman who had a tumour removed from her neck." src="https://images.theconversation.com/files/386130/original/file-20210224-13-4s41p1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386130/original/file-20210224-13-4s41p1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386130/original/file-20210224-13-4s41p1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386130/original/file-20210224-13-4s41p1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386130/original/file-20210224-13-4s41p1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386130/original/file-20210224-13-4s41p1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386130/original/file-20210224-13-4s41p1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Understanding the importance of timely cancer treatment is nothing new.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=12265958">Wikimedia Commons</a></span>
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<p>Doctors lamented the patients who, “<a href="https://muse.jhu.edu/article/456168">because of their praiseworthy modesty</a>”, consulted too late for effective treatment. Medical textbooks designed to be read by patients told their readers that “were proper means used in due time, a cancer might often be prevented; but after the disorder has arrived at a certain height it generally sets all medicine at defiance”.</p>
<p>Looking at this longer history of cancer reminds us of the emotional <em>and</em> physical costs of any delays. After all, even if these waits have only minimal effects on patients’ survival or long-term health, we must also think about the psychological trauma of living in limbo. Particularly when that limbo is associated with cancer, a disease that has long carried with it a sense of profound anxiety, so much so that in the 19th century it was often termed “the dread disease”. It is often understood as an alien invader, now very much outstaying its welcome. </p>
<p>As the COVID-19 crisis slowly abates, we must not just look back with regret at the number of people killed by the virus or celebrate the success of vaccines. We must instead assess the pandemic’s impact in the round and consider the physical as well as emotional costs of a disease that turned our world upside down. When the next pandemic comes, we must be prepared to not only treat the victims of epidemic disease but to continue to provide the fundamental healthcare services we need to stay both healthy and happy.</p><img src="https://counter.theconversation.com/content/155608/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Arnold-Forster is a core collaborator on the Wellcome Trust-funded Healthy Scepticism project.</span></em></p>We should assess the pandemic’s effect in the round, beyond just COVID deaths.Agnes Arnold-Forster, Research Fellow, History of Medicine and Healthcare, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1531112021-01-15T14:03:31Z2021-01-15T14:03:31ZDigital hoarders: we’ve identified four types – which are you?<figure><img src="https://images.theconversation.com/files/378579/original/file-20210113-13-xts4og.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/filing-archives-cabinet-on-laptop-screen-665882623">rawf8/Shutterstock</a></span></figcaption></figure><p>How many emails are in your inbox? If the answer is thousands, or if you often struggle to find a file on your computer among its cluttered hard drive, then you might be classed as a digital hoarder. </p>
<p>In the physical world, hoarding disorder has been recognised as <a href="http://www.hoardingandsqualorsa.com.au/resources/DSM%205%20-%20Hoarding%20disorder%20definition.pdf">a distinct psychiatric condition</a> among people who accumulate excessive amounts of objects to the point that it prevents them living a normal life. Now, research has begun to recognise that hoarding can be a problem in the digital world, too.</p>
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Read more:
<a href="https://theconversation.com/for-some-people-anxiety-and-phobias-are-taken-to-extremes-19672">For some people, anxiety and phobias are taken to extremes</a>
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<p>A case study <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4600778/">published in the British Medical Journal</a> in 2015 described a 47-year-old man who, as well as hoarding physical objects, took around 1,000 digital photographs every day. He would then spend many hours editing, categorising, and copying the pictures onto various external hard drives. He was autistic, and may have been a collector rather than a hoarder — but his digital OCD tendencies caused him much distress and anxiety.</p>
<p>The authors of this research paper defined digital hoarding as “the accumulation of digital files to the point of loss of perspective which eventually results in stress and disorganisation”. By surveying hundreds of people, my colleagues and I found that digital hoarding is <a href="https://www.sciencedirect.com/science/article/pii/S0747563219300469">common in the workplace</a>. In a follow-up study, in which we interviewed employees in two large organisations who exhibited lots of digital hoarding behaviours, we identified <a href="https://academic.oup.com/iwc/article-abstract/32/3/209/5898270?redirectedFrom=fulltext">four types of digital hoarder</a>.</p>
<p>“Collectors” are organised, systematic and in control of their data. “Accidental hoarders” are disorganised, don’t know what they have, and don’t have control over it. The “hoarder by instruction” keeps data on behalf of their company (even when they could delete much of it). Finally, “anxious hoarders” have strong emotional ties to their data — and are worried about deleting it.</p>
<h2>Working life</h2>
<p>Although digital hoarding doesn’t interfere with personal living space, it can clearly have a negative impact upon daily life. Research also suggests digital hoarding <a href="https://crestresearch.ac.uk/resources/cybersecurity-risks-of-digital-hoarding-behaviours/">poses a serious problem</a> to businesses and other organisations, and even has a negative impact on the environment.</p>
<p>To assess the extent of digital hoarding, we initially surveyed more than 400 people, many of whom admitted to hoarding behaviour. Some people reported that they kept many thousands of emails in inboxes and archived folders and never deleted their messages. This was especially true of work emails, which were seen as potentially useful as evidence of work undertaken, a reminder of outstanding tasks, or were simply kept “just in case”.</p>
<figure class="align-center ">
<img alt="Man at computer confornted by many email notifications" src="https://images.theconversation.com/files/378580/original/file-20210113-21-dwnt4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/378580/original/file-20210113-21-dwnt4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/378580/original/file-20210113-21-dwnt4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/378580/original/file-20210113-21-dwnt4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/378580/original/file-20210113-21-dwnt4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/378580/original/file-20210113-21-dwnt4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/378580/original/file-20210113-21-dwnt4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Saving work emails is a common form of digital hoarding.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/email-inbox-electronic-communication-graphics-concept-401507503">Rawpixel.com/Shutterstock</a></span>
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<p>Interestingly, when asked to consider the potentially damaging consequences of not deleting digital information – such as the cybersecurity threat to confidential business information – people were clearly aware of the risks. Yet the respondents still showed a great reluctance to hit the delete button. </p>
<p>At first glance, digital hoarding may not appear much of a problem — especially if digital hoarders work for large organisations. Storage is cheap and effectively limitless thanks to internet “cloud” storage systems. But digital hoarding may still lead to negative consequences. </p>
<p>First, storing thousands of files or emails is inefficient. Wasting large amounts of time looking for the right file can reduce productivity. Second, the more data is kept, the greater the risk that a cyberattack could lead to the loss or theft of information covered by data protection legislation. In the EU, <a href="https://ico.org.uk/media/for-organisations/data-protection-reform/overview-of-the-gdpr-1-13.pdf">new GDPR rules</a> mean companies that lose customer data to hacking could be hit with hefty fines.</p>
<p>The final consequence of digital hoarding — in the home or at work — is an environmental one. Hoarded data has to be stored somewhere. The reluctance to have a digital clear-out can contribute to the development of increasingly large servers that use <a href="https://www.independent.co.uk/environment/global-warming-data-centres-to-consume-three-times-as-much-energy-in-next-decade-experts-warn-a6830086.html">considerable amounts of energy</a> to cool and maintain them.</p>
<figure class="align-center ">
<img alt="A long corridor of servers" src="https://images.theconversation.com/files/378583/original/file-20210113-17-72g3rs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/378583/original/file-20210113-17-72g3rs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/378583/original/file-20210113-17-72g3rs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/378583/original/file-20210113-17-72g3rs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/378583/original/file-20210113-17-72g3rs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/378583/original/file-20210113-17-72g3rs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/378583/original/file-20210113-17-72g3rs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Data stored online is saved on servers, which have a large carbon footprint.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/white-servers-data-center-room-computers-1464134255">sedcoret/Shutterstock</a></span>
</figcaption>
</figure>
<h2>How to tackle digital hoarding</h2>
<p>Research has shown that physical hoarders can <a href="https://www.health.harvard.edu/blog/cant-let-go-hoarding-201405227163">develop strategies</a> to reduce their accumulation behaviours. While people can be helped to stop accumulating, they are more resistant when it comes to actually getting rid of their cherished possessions — perhaps because <a href="https://www.sciencedirect.com/science/article/pii/S0191886914004863">they “anthropomorphise” them</a>, treating inanimate objects as if they had thoughts and feelings. </p>
<p>We don’t yet know enough about digital hoarding to see whether similar difficulties apply, or whether existing coping strategies will work in the digital world, too. But we have found that asking people how many files they think they have often surprises and alarms them, forcing them to reflect on their digital accumulation and storing behaviours.</p>
<p>As hoarding is often <a href="https://www.sciencedirect.com/science/article/abs/pii/S000579670100136X">associated with anxiety and insecurity</a>, addressing the source of these negative emotions may alleviate hoarding behaviours. Workplaces can do more here, by reducing non-essential email traffic, making it very clear what information should be retained or discarded, and by delivering training on workplace data responsibilities. </p>
<p>In doing so, companies can reduce the anxiety and insecurity related to getting rid of obsolete or unnecessary information, helping workers to avoid the compulsion to obsessively save and store the bulk of their digital data.</p><img src="https://counter.theconversation.com/content/153111/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Neave receives funding from CREST (Centre for Research
and Evidence on Security Threats) —an independent Centre commissioned
by the UK Economic and Social Research Council (ESRC). </span></em></p>Physical hoarding has been studied for decades - but now, new forms of digital hoarding are emerging.Nick Neave, Associate Professor in Psychology, and Director of the Hoarding Research Group, Northumbria University, NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1494222020-11-17T13:22:32Z2020-11-17T13:22:32ZHoarding, stockpiling, panic buying: What’s normal behavior in an abnormal time?<figure><img src="https://images.theconversation.com/files/369168/original/file-20201112-23-1t4qlhq.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C3958%2C2970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hoarding, stockpiling and panic buying have all increased during the pandemic. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-carries-heap-of-toilet-paper-royalty-free-image/1213254321?adppopup=true">Grace Cary via Getty Images</a></span></figcaption></figure><p>Symptoms of <a href="https://formative.jmir.org/2020/10/e22043/">depression, anxiety and obsessive compulsive disorders</a> have emerged or worsened for many during the pandemic. This is no surprise to clinicians and scientists, who have been increasing worldwide access to mental health information and <a href="https://wellness.med.ufl.edu/">resources</a>. </p>
<p>But what effect has the pandemic had on another common but often misunderstood problem – hoarding? The issue first received attention when people piled up paper towels, toilet tissue and hand sanitizer in their shopping carts <a href="https://www.cnbc.com/2020/03/11/heres-why-people-are-panic-buying-and-stockpiling-toilet-paper.html">at the start of the pandemic</a>, leading some people to wonder whether they or a loved one were showing signs of hoarding disorder.</p>
<p>The short answer is: Probably not. Hoarding disorder goes beyond stockpiling in an emergency. <a href="https://scholar.google.com/citations?user=GuqlxnAAAAAJ&hl=en">I am a psychiatrist</a> at the University of Florida and the director of the <a href="https://coard.psychiatry.ufl.edu/">Center for OCD, Anxiety and Related Disorders</a>. I also recently <a href="https://wwnorton.com/books/9780393713572/about-the-book/reviews">authored a book</a> on hoarding disorder. My work focuses on identifying the causes of hoarding and its impact on individuals and on society.</p>
<figure class="align-center ">
<img alt="Millions of Americans have hoarding disorder." src="https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Millions of Americans have hoarding disorder, a serious psychiatric illness.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/abandoned-home-royalty-free-image/157568086?adppopup=true">shaunl via Getty Images</a></span>
</figcaption>
</figure>
<h2>Millions have hoarding disorder</h2>
<p>Although often sensationalized in the popular press as a behavioral <a href="https://dailytitan.com/opinion/the-way-the-media-portrays-mental-illnesses-like-hoarding-and-ocd-maintain-harmful-stereotypes/article_f1edb9a1-33ad-521e-98c2-90eef9486df5.html">oddity</a>, <a href="https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder">hoarding disorder</a> is a serious psychiatric illness affecting more than 13 million American adults. The cause is a complex interaction of biological and environmental factors. Doctors have known about hoarding for centuries, although the disorder was only formally recognized by the psychiatric community as a <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">distinct psychiatric illness</a> in 2013. Perhaps the most famous person who had a hoarding disorder was <a href="http://indianmentalhealth.com/pdf/2015/vol2-issue2/The_Aviator.pdf">Howard Hughes</a>. </p>
<p>The disorder is chronic and often lifelong. Although symptoms typically begin in <a href="https://doi.org/10.1002/da.22896">adolescence</a>, they usually do not become problematic until mid- to late adulthood. No one knows exactly why the disorder takes so long to manifest; perhaps as those with hoarding symptoms get older, their ability to decide what to discard becomes increasingly impaired. Or they might have fewer people around, like parents or spouses, to encourage them to get rid of unneeded items. </p>
<p>What is clear is that the increase in hoarding behaviors across the lifespan is not just a result of a lifetime’s accumulation of clutter. About <a href="https://doi.org/10.1016/j.jagp.2016.11.006">7% of adults</a> over age 60 have problematic hoarding; that’s one in every 14 people. </p>
<p>And contrary to popular belief, the defining feature of hoarding disorder is not clutter. Instead, it is the difficulty in discarding what’s no longer needed. The most commonly hoarded items are everyday belongings: clothes, shoes, containers, tools and mechanical objects like nails and screws, household supplies, newspapers, mail and magazines. Those with the disorder report feeling indecision about what to discard, or fear the item will be needed in the future. </p>
<p>This trouble in disposing of items, even common items like junk mail, plastic bags and plastic containers, leads to the accumulation of clutter. Over time, living and work spaces become unusable. In addition to affecting living spaces, hoarding also causes problems between spouses, between parents and their children, and between friends. At its worst, hoarding can also impact one’s ability to work. </p>
<p>Hoarding disorder has a substantial impact on public health, including not only <a href="https://doi.org/10.1016/j.psychres.2007.08.008">lost work days</a> but also increased rates of <a href="https://doi.org/10.1080/13607863.2013.814105">medical illness</a>, <a href="https://doi.org/10.1016/j.jocrd.2018.11.001">depression, anxiety</a>, risk of suicide and <a href="https://doi.org/10.1002/da.22439">cognitive impairment</a>. As many as half of those suffering from hoarding disorder will also suffer from depression, and 30% or more will have an anxiety disorder. </p>
<p>Hoarding-related clutter in homes increases the <a href="https://www.mentalhealthsf.org/wp-content/uploads/2016/12/BeyondOverwhelmed.pdf">risk of falls</a>, pest or vermin infestation, unstable or unsafe living conditions and difficulty with self-care. It may stun you to know that up to 25% of <a href="https://digitalcommons.wpi.edu/iqp-all/592/">deaths by house fire</a> are due to hoarding. </p>
<figure class="align-center ">
<img alt="During the pandemic, stores across the U.S. ran out of common household items, like toilet paper." src="https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Because of excessive stockpiling and panic buying, stores across the U.S. ran out of common household items during the pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/general-view-of-the-empty-toilet-paper-and-paper-towel-news-photo/1207061653?adppopup=true">Icon Sportswire via Getty Images</a></span>
</figcaption>
</figure>
<h2>Stockpiling and panic buying</h2>
<p>What is the difference between stockpiling, panic buying and hoarding? Will someone who stockpiled toilet paper and hand sanitizer in the early days of the pandemic develop hoarding disorder? Or are they instead rational and thoughtful planners?</p>
<p>While these terms are often used interchangeably, stockpiling and panic buying are not symptoms of hoarding disorder. Nor are they necessarily the result of a psychiatric or psychological condition. Instead, <a href="https://www.merriam-webster.com/dictionary/stockpile">stockpiling</a> is a normal behavior that many people practice in preparation for a known or anticipated shortage. The goal of stockpiling is to create a reserve in case there’s a future need.</p>
<p>For example, people who live in cold climates may stock up on wood for fireplaces and salt for driveways before the winter. Similarly, those who live in the southeast U.S. may stock up on gasoline and water before hurricane season.</p>
<p>That said, stockpiling can be excessive. During a crisis, it can lead to national shortages of essential items. This occurred early in the pandemic, when people bought toilet paper in large quantities and emptied store shelves for everyone else. </p>
<p>Ironically, the more media attention on stockpiling, the more it triggers <a href="https://doi.org/10.1111/bjhp.12480">additional stockpiling</a>. People reading about a potential shortage of hand sanitizer will be driven to buy as much as possible until it’s no longer available for weeks or months.</p>
<p>While stockpiling is planned, <a href="https://en.wikipedia.org/wiki/Panic_buying">panic buying</a> is an impulsive and temporary reaction to anxiety caused by an impending crisis. Items, even if unneeded, may be purchased simply because they are available on store shelves. Panic buying may also include purchasing enormous quantities of a particular item, in volumes that will never be needed, or emptying a store shelf of that item. Panic acquiring, which involves getting free things through giveaways, food pantries or scavenging, also occurs during a crisis. </p>
<p>Unlike those with hoarding disorder, panic buyers and stockpilers are able to discard something no longer needed. Usually, after the crisis has passed, they can easily throw or give these items away. </p>
<h2>How to get help</h2>
<p>For some with hoarding disorder, the pandemic has made it even harder to dispose of unneeded items. Others find their material belongings provide comfort and safety in the face of increased uncertainty. Yet others have used the lockdowns as a reset – time to finally declutter their home. </p>
<p>If you or someone you know has problems with hoarding, help is available. Resources are on the <a href="https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder">American Psychiatric Association</a> website and at the <a href="https://hoarding.iocdf.org/">International Obsessive Compulsive Foundation</a>.</p><img src="https://counter.theconversation.com/content/149422/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carol Mathews receives funding from the National Institute of Health. She is affiliated with the Tourette Association of America, and the International Obsessive Compulsive Foundation. She is the author of the book: Recognizing and Treating Hoarding Disorder: How Much is Too Much? published by W.W. Norton & Co.</span></em></p>The pandemic has put a spotlight on a once little-discussed disorder – hoarding. But hoarding disorder is not what you might think.Carol Mathews, Professor of Psychiatry, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1440852020-08-07T09:05:07Z2020-08-07T09:05:07ZTransgender and gender diverse people up to six times more likely to be autistic – new study<figure><img src="https://images.theconversation.com/files/351628/original/file-20200806-22-pfestv.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5599%2C3732&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Transgender and gender diverse people are more likely to be autistic.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/transgender-boy-tearingfemale-male-paper-over-614171012"> Sandra van der Steen/Shutterstock</a></span></figcaption></figure><p>There is a lot of evidence to suggest that men are more likely to be autistic than women. For every woman who is autistic, evidence suggests that as many as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4164392/">four men are autistic</a>. But studies investigating this often use the terms “sex assigned at birth” and “gender identity” interchangeably. </p>
<p>When someone is born, they are assigned a sex, typically boy or girl, based on their genitals. But gender identity is a person’s own sense of their gender, which may differ from the sex they were assigned at birth. </p>
<p>We use the term “cisgender” to refer to people whose sex corresponds to their gender. And we use the term “transgender and gender diverse” to refer to people whose gender is different from their sex and to describe the diversity of gender identities beyond the binary. </p>
<p>There is <a href="https://pubmed.ncbi.nlm.nih.gov/26753812/">some evidence</a> to suggest that transgender and gender-diverse people are more likely to be autistic than cisgender people. But the evidence has largely come from small studies, typically conducted using people who are referred to gender-identity clinics. </p>
<p>Not all transgender and gender-diverse people are or need to be referred to gender-identity clinics. So, is the likelihood of autism higher in transgender and gender-diverse people, regardless of whether they were referred to gender identity clinics?</p>
<p>To answer this question, we gained access to five datasets, where participants had provided information about their gender and diagnostic information of autism and other neurodevelopmental and psychiatric conditions. They also completed a questionnaire about autistic traits which are non-clinical features of autism. We obtained data from over 600,000 adults from different countries and at different ages. </p>
<p>In our latest study, published in <a href="https://www.nature.com/articles/s41467-020-17794-1">Nature Communications</a>, we found that transgender and gender-diverse adults were between three and six times more likely to be diagnosed as autistic compared with cisgender adults. But this only includes diagnosed autism – and many adults on the spectrum may be undiagnosed. We estimate that around 1-1.5% of the global population may be autistic. This would suggest that somewhere between 3-9% of transgender and gender-diverse adults may be autistic. </p>
<p>We also found that, regardless of an autism diagnosis, transgender and gender-diverse adults were also more likely to report a higher level of autistic traits compared with cisgender adults. We know that autism may present slightly differently in cisgender men and women. Yet we don’t know if autism presents differently in transgender and gender-diverse individuals – and this is something we need to understand to ensure that doctors can better identify autism in this group.</p>
<p>But it was not just autism diagnoses that were elevated in this group. Indeed, we find that diagnoses of conditions such as depression, attention deficit hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD) were also elevated in transgender and gender-diverse adults compared with cisgender adults. </p>
<h2>Poorly understood needs</h2>
<p>The needs of transgender and gender-diverse people remain poorly understood. They regularly face discrimination, abuse and harassment. And in many places their identity is questioned with little legal safeguarding of their rights. Anyone, regardless of their gender, who has faced such adversities is likely to have poor mental health. As researchers, we must identify and address the factors that contribute to poor mental health in this group. </p>
<figure class="align-center ">
<img alt="A person holds a sign that reads: 'Trans Rights Are Human Rights' at a march." src="https://images.theconversation.com/files/351629/original/file-20200806-16-1v7kv4f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/351629/original/file-20200806-16-1v7kv4f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/351629/original/file-20200806-16-1v7kv4f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/351629/original/file-20200806-16-1v7kv4f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/351629/original/file-20200806-16-1v7kv4f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/351629/original/file-20200806-16-1v7kv4f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/351629/original/file-20200806-16-1v7kv4f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Transgender and gender diverse people often face discrimination.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/red-pedometer-studio-isolated-on-white-28888600">Justin Starr Photography/Shutterstock</a></span>
</figcaption>
</figure>
<p>We recognise that grouping all transgender and gender-diverse people into one group is reductionist. Different people identify as transgender and gender-diverse for very different reasons – and their needs will differ. In the current study, we were limited by how gender was recorded – we need better methods to record gender to better capture the differing mental health needs in this group of people. It is an urgent priority to understand the clinical needs of this vulnerable group so as to provide the most appropriate support.</p><img src="https://counter.theconversation.com/content/144085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Latest study confirms robust link between transgender and gender-diverse people and autism.Varun Warrier, Doctoral Scientist, University of CambridgeSimon Baron-Cohen, Professor of Developmental Psychopathology, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1402052020-06-15T12:26:14Z2020-06-15T12:26:14ZAre we all OCD now? Coronavirus fears blur the line between obsessive-compulsive and safety amid a dangerous pandemic<figure><img src="https://images.theconversation.com/files/341346/original/file-20200611-80770-1j24wdv.jpg?ixlib=rb-1.1.0&rect=0%2C65%2C2712%2C1643&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What once looked like obsessive-compulsive disorder has become normal when faced with a deadly pandemic. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/double-exposure-portrait-of-face-of-young-man-royalty-free-image/1219500833">Busà Photography via Getty Images</a></span></figcaption></figure><p>One of the hallmarks of <a href="https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml">obsessive-compulsive disorder</a> is contamination fears and excessive hand-washing. Years ago, a patient with severe OCD came to my office wearing gloves and a mask and refused to sit on any of the “contaminated” chairs. Now, these same behaviors are accepted and <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html">even encouraged</a> to keep everyone healthy. </p>
<p>This new normal in the face of a deadly pandemic has permeated our culture and will continue to influence it. Many stores now prominently post rules mandating face masks and hand sanitizer use and limit the number of customers allowed inside at one time. Walkers and joggers politely cross the street to avoid proximity to each other.</p>
<p>Only a few months ago, this type of behavior would have been considered excessive and certainly not healthy.</p>
<p>So, where do doctors draw the line between vigilance to avoid being infected with the coronavirus and obsessive-compulsive disorder that can be harmful?</p>
<p>This is an important question that I, a <a href="https://www.med.wayne.edu/profile/aa3409">psychiatrist</a>, and my co-author, a wellness and parenting coach, often hear. </p>
<h2>Adaptation or internet addiction?</h2>
<p>Since the start of the pandemic, it has become more challenging to assess behaviors that were once considered excessive. Many behaviors previously considered pathological are now considered essential to protect human health and are applauded as adaptive and resourceful.</p>
<p>Before COVID-19, concerns about <a href="https://doi.org/10.2174/157340012803520513">compulsive use of the internet or internet addiction</a>, characterized by overuse and overdependence on digital devices, were growing. </p>
<p>During the pandemic, however, society has quickly adapted online opportunities. Whenever possible, people are working from home, attending school online and socializing through online book clubs. Even certain health care needs are increasingly being met remotely through telehealth and telemedicine.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/341344/original/file-20200611-80750-1qex5g9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/341344/original/file-20200611-80750-1qex5g9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/341344/original/file-20200611-80750-1qex5g9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/341344/original/file-20200611-80750-1qex5g9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/341344/original/file-20200611-80750-1qex5g9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/341344/original/file-20200611-80750-1qex5g9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/341344/original/file-20200611-80750-1qex5g9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Technology has become a lifeline during the pandemic, allowing people to work, go to school and keep in touch with family and friends all from home.</span>
<span class="attribution"><span class="source">Peter Dazeley/ImageBank via Getty</span></span>
</figcaption>
</figure>
<p>Overnight, <a href="https://www.usnews.com/news/health-news/articles/2020-03-28/staying-at-home-during-the-pandemic-use-technology-to-stay-connected">digital connections have become commonplace</a>, with many of us feeling fortunate to have this access. Similar to contamination fears, some digital behaviors that were once questioned have become adaptive behaviors that keep us healthy – but not all of them. </p>
<h2>Is it obsessive-compulsive or protective?</h2>
<p>While COVID-19-era behaviors may look like clinical OCD, there are key distinctions between protective behaviors in the face of a clear and present danger like a pandemic and a clinical diagnosis of OCD. </p>
<p>The repetitive, ritualistic thoughts, ideas and behaviors seen in <a href="https://beyondocd.org/information-for-individuals/clinical-definition-of-ocd">clinical OCD</a> are very time-consuming for people dealing with them, and they significantly interfere with several important areas of the person’s life, including work, school and social interactions. </p>
<p>Some people have obsessive-compulsive traits that are less severe. These traits are often observed in high-achieving people and are not clinically debilitating. Such “keep the eye on the prize” behaviors are recognized in nearly <a href="https://doi.org/10.1097/00004583-199407000-00002">20% of the population</a>. A talented chef who is very attentive to detail may be referred to as “obsessive-compulsive.” So may a detail-oriented engineer building a bridge or an accountant doing taxes by examining files from many different angles. </p>
<p>The critical difference is that the persistent, repetitive, ritualistic thoughts, ideas and behaviors seen in those suffering from clinical OCD often take over the person’s life. </p>
<p>When most of us check the door once or twice to make sure it is locked or wash our hands or use sanitizer after going to the grocery store or using the restroom, our brains send us the “all clear” signal and tell us it is safe to move on to other things. </p>
<p>A person with OCD never gets the “all clear” signal. It is not uncommon for a person with OCD to spend several hours per day <a href="https://www.penguinrandomhouse.com/books/325571/the-boy-who-couldnt-stop-washing-by-judith-l-rapoport/">washing their hands</a> to the point their skin becomes cracked and bleeds. Some people with OCD have checking rituals that prevent them from ever leaving their home. </p>
<h2>OCD triggers have become harder to avoid</h2>
<p>The same principles that apply to compulsive hand-washing behaviors also apply to compulsive use of the internet and electronic devices. Excessive use can interfere with work and school and harm psychological and social functioning. Besides social and familial problems, those behaviors can lead to medical problems, including back and neck pain, obesity and eye strain. </p>
<p>The American Pediatric Association recommends that teenagers spend no more than <a href="https://doi.org/10.1542/peds.2016-2592%5D(https://doi.org/10.1542/peds.2016-2592">two hours per day</a> using the internet or electronic devices. Some teenagers with internet addiction are spending as many as 80-100 hours per week on the internet, refusing to do anything else, including their schoolwork, outside activities and interacting with their families. The digital world becomes a black hole that is increasingly difficult for them to escape.</p>
<p>For those who struggle with compulsive use of the internet and social media, the new, increased demands to use digital platforms for work, school, grocery shopping and extracurricular activities can open the black hole even further.</p>
<p>People with pre-pandemic contamination fears, or who previously were unable to regulate their use of technology, find trigger situations that were once avoidable have now become even more ubiquitous.</p>
<h2>Keeping the threat response in check</h2>
<p>As new behavioral norms evolve due to the changing social conditions, the way that certain behaviors are identified and described may also evolve. Expressions such as being “so OCD” or “addicted to the internet” may take on different meanings as frequent hand-washing and online communication become common.</p>
<p>For those of us adapting to our new normal, it is important to recognize that it is healthy to follow new guidelines for social distancing, washing hands and wearing masks, and that it is OK to spend extra time on the internet or other social media with the new limits on personal interactions. However, if internet use or hand-washing becomes uncontrollable or “compulsive,” or if intrusive “obsessive” thoughts about cleanliness and infection become problematic, it’s time to seek help from a mental health professional.</p>
<p><em>Roen Chiriboga, a wellness and parenting coach in Troy, Michigan, contributed to this article.</em></p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/140205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Rosenberg receives funding from the Children’s Hospital of Michigan Foundation, Detroit, MI, and a grant from the National Institute of Mental Health (R01MH59299). This work was also supported in part by the State of Michigan Lycaki Young Fund and the Detroit Wayne Integrated Health Network.</span></em></p>Behaviors that would have been seen as pathological a few months ago are now applauded as adaptive and resourceful. Where do doctors draw the line?David Rosenberg, Professor of Psychiatry and Neuroscience, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1331662020-03-06T15:26:50Z2020-03-06T15:26:50ZCoronavirus: how to stop the anxiety spiralling out of control<figure><img src="https://images.theconversation.com/files/319074/original/file-20200306-118956-1r3nfw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Don't let fear ruin your life.</span> <span class="attribution"><a class="source" href="https://www.cambridge.org/core/journals/psychological-medicine/article/global-prevalence-of-anxiety-disorders-a-systematic-review-and-metaregression/484845CE01E709EE4FB6554AA78E612F">TeamDAF</a></span></figcaption></figure><p>As <a href="https://theconversation.com/the-hunt-for-a-coronavirus-cure-is-showing-how-science-can-change-for-the-better-132130">the coronavirus</a> proliferates on a global scale, worry and panic <a href="https://www.nbcnews.com/better/lifestyle/coronavirus-fears-have-emptied-supermarket-shelves-are-you-panic-buying-ncna1148536">is on the rise</a>. And it is no wonder when we are constantly being told how to <a href="https://theconversation.com/yes-washing-our-hands-really-can-help-curb-the-spread-of-coronavirus-132915">best protect ourselves</a> from being infected. But how do you stay safe in this climate and simultaneously make sure that the fear doesn’t take over your life, developing into obsessive compulsive disorder or panic?</p>
<p>Fear is a normal, necessary evolutionary response to threat – ultimately designed to keep us safe. Whether the threat is emotional, social or physical, this response is dependent on a <a href="https://www.sciencedirect.com/science/article/pii/S0166223696100692">complex interaction</a> between our primitive “animal brain” (the limbic system) and our sophisticated cognitive brain (the neo-cortex). These work busily in concert to assess and respond to threats to survival. </p>
<p>Once a threat has been identified, a <a href="https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response">“fight or flight” response</a> can be triggered. This is the body’s biological response to fear and involves flooding us with adrenaline in a bid to ensure that we are able to escape or defeat any threat, such as a dangerous animal attacking. The response produces a range of intense physical symptoms – palpitations, perspiration, dizziness and difficulty breathing – which are designed to make us run faster and fight harder. </p>
<p>However, this system can be prone to glitches, sometimes responding disproportionately to threats that aren’t actually that serious or imminent. Worrying about health conditions such as heart attacks, stroke and even COVID-19 (the disease caused by the coronavirus) can therefore also trigger a fight-or-flight response.</p>
<p>That’s despite the fact that there is no role for a primitive biological response to COVID-19 – no running or fighting is necessary. Instead, it is our high-level, cognitive neocortex that is required here, a rational and measured approach to infectious disease, without the messy complications of panic. </p>
<p>Sadly, this is easier said than done. Once the fear has kicked in, it can be hard to stop it. </p>
<h2>Vulnerable groups</h2>
<p>It is highly unlikely that a viral outbreak, even at pandemic levels, will trigger mental health problems in people who don’t already have them or are in the process of developing them. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1925038/">Research shows</a> that most mental health problems start between early adolescence and the mid-20s, with <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/development-of-anxiety-disorders-in-childhood-an-integrative-review/78CA4C983719D652402CA1F5A0E259DD">complex factors being involved</a>. Around 10% of the global population experience clinical levels of anxiety at any one time, although some estimates are higher. </p>
<p>People who are chronically and physically unwell – the ones who are the most vulnerable to the coronavirus – are at particular risk of spiralling anxiety. This should not be ignored. Their concern is warranted and is vital in motivating them to take up precautionary measures. But it is important that these individuals have the support they need in dealing with their emotions.</p>
<p>People with health anxiety, preoccupied with health-related information or physical symptoms, are also at risk of worsening mental health as the virus spreads. So are individuals who are prone to frequent or increased “checking”, such as constantly making sure that the oven is off or that the front door is locked. Those at the extreme end of the scale when it comes to such behaviour may be displaying signs of <a href="https://theconversation.com/brain-scans-reveal-why-it-is-so-difficult-to-recover-from-ocd-and-hint-at-ways-forward-74092">obsessive compulsive disorder</a>.</p>
<p>People who have a lot of background anxiety, and are not easily reassured, may also benefit from assessment and support in the shadow of the coronavirus outbreak. This may include people with <a href="https://theconversation.com/explainer-what-is-an-anxiety-disorder-8206">generalised anxiety disorder or panic disorder</a>, which have strong physiological features.</p>
<h2>Ways to manage the stress</h2>
<p>If you find yourself excessively worrying about the coronavirus, this doesn’t necessarily mean that you have a psychological disorder. But high levels of emotional distress, whatever the source, should be appropriately and compassionately attended to, particularly if it is interfering with normal day to day activities.</p>
<p>At times of stress and anxiety, we are often prone to using strategies that are designed to help but <a href="https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/importance-of-behaviour-in-the-maintenance-of-anxiety-and-panic-a-cognitive-account/B3BAA0EFEF179C99BBCA5F983B05A534">prove counter-productive</a>. For example, you may Google symptoms to try to calm yourself down, even though it is unlikely to ever make you feel better. When our strategies for de-stressing instead increase our anxiety, it is time to take a step back and ask if there is anything more helpful we can do.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/319076/original/file-20200306-118966-1ai11pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/319076/original/file-20200306-118966-1ai11pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/319076/original/file-20200306-118966-1ai11pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/319076/original/file-20200306-118966-1ai11pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/319076/original/file-20200306-118966-1ai11pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/319076/original/file-20200306-118966-1ai11pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/319076/original/file-20200306-118966-1ai11pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Stop checking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-beautiful-asian-chinese-student-woman-1631236618">TeamDAF</a></span>
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<p>There are actually ways to dampen down the physical and emotional symptoms associated with anxiety. One is to stop checking. For example, avoid looking for signs of illness. You are likely to find unfamiliar physical sensations that are harmless but make you feel anxious. Normal physical changes and sensations pass in time, so if you feel your chest tighten, shift your focus onto pleasurable activities and adopt “watchful waiting” in the meantime.</p>
<p>In the case of COVID-19, checking may also include constant monitoring of news updates and social media feeds, which significantly increases anxiety – only serving to reassure us momentarily, if at all. So if you are feeling anxious, consider tuning off automatic notifications and updates on COVID-19. </p>
<p>Instead, do less frequent checks of reliable, impartial sources of information updates on COVID-19. This might include national health websites rather than alarmist news or social media feeds that exacerbate worry unnecessarily. Information can be reassuring if it is rooted in facts. It is often the <a href="https://www.sciencedirect.com/science/article/pii/S0005796707000952">intolerance of uncertainty</a> that perpetuates anxiety rather than fear of illness itself. </p>
<p>At times of stress and anxiety, hyperventilation and shallow breathing is common. Purposeful, regular breathing can therefore <a href="https://link.springer.com/article/10.1007/s10484-015-9279-8">work to reset</a> the fight or flight response and prevent the onset of panic and the unpleasant physical symptoms associated with anxiety. This is also true for exercise, which can help reduce the excess adrenaline build-up associated with anxiety. It can also give much needed perspective. </p>
<p>Perhaps most importantly, don’t isolate yourself. Personal relationships are crucial in maintaining perspective, elevating mood and allowing distraction away from concerns that trouble us. Even in imposed isolation, it is important to combat loneliness and keep talking – for example, via video chats. </p>
<p>We are globally united in living with a very real yet uncertain health threat. Vigilance and precautionary measures are essential. But psychological distress and widespread panic does not have to be part of this experience. Continuing normal daily activities, maintaining perspective and reducing unnecessary stress is key to psychological survival. In other words, where possible, keep calm and carry on. </p>
<p>If you continue to feel anxious or distressed despite trying these techniques, do talk to your GP or refer to a psychologist for evidence-based treatment such as cognitive behavioural therapy.</p><img src="https://counter.theconversation.com/content/133166/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jo Daniels does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stop constant checking and stay social.Jo Daniels, Senior Lecturer of Psychology, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1064852018-11-20T10:29:12Z2018-11-20T10:29:12ZSimple smartphone app that could help OCD sufferers<figure><img src="https://images.theconversation.com/files/246264/original/file-20181119-76157-1to3e6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A smartphone app could replace compulsive behaviours, like excessive hand washing.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sudsy-hands-soap-water-53711752">Laborant/ Shutterstock</a></span></figcaption></figure><p>Imagine feeling anxious every time you touched a doorknob or dirty surface – maybe even spending hours washing and scrubbing your hands afterwards, sometimes until they bleed. For sufferers of Obsessive Compulsive Disorder (OCD), especially those with <a href="https://www.sciencedirect.com/science/article/pii/S0272735809001366">contamination fears</a>, managing the disorder in daily life can be difficult. </p>
<p>The current treatments for this type of OCD are either antidepressants or <a href="https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/">cognitive behavioural therapy</a>. However, almost 40% of OCD sufferers currently <a href="https://jonathanhaverkampf.ie/wp/wp-content/uploads/2017/02/Treatment-Resistant-OCD-CJ-Haverkampf-J-Psychiatry-Psychotherapy-Communication-2014-Sep-30-3391-94.pdf">fail to respond</a> to these types of treatments. But my colleagues and I have started researching new and innovative ways to manage and treat OCD – and it might be as simple as using a smartphone app. </p>
<p>We have developed a new treatment app that includes videos that simulate compulsive behaviours (such as hand washing) or which have some similarities to current psychological treatments (such as touching a disgusting object). This may help with reducing anxiety or overcoming contamination fears. The app also has a thumbs up or down system to allow users to rate how they are feeling, how anxious they are, how disgusted they are feeling and how strongly they want to wash their hands.</p>
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Read more:
<a href="https://theconversation.com/brain-scans-reveal-why-it-is-so-difficult-to-recover-from-ocd-and-hint-at-ways-forward-74092">Brain scans reveal why it is so difficult to recover from OCD – and hint at ways forward</a>
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<p>Diagnoses of this type of OCD are currently done by a clinician using self-report questionnaires – such as the <a href="https://iocdf.org/wp-content/uploads/2016/04/04-Y-BOCS-w-Checklist.pdf">Yale-Brown Obsessive Compulsive scale (YBOCS)</a> and the <a href="http://www.caleblack.com/psy5960_files/OCI-R.pdf">Obsessive-Compulsive Inventory (OCI-R)</a>. These questionnaires ask patients to answer a variety of questions and statements to determine the severity of their OCD symptoms. </p>
<p>Another test is to measure cognitive rigidity and flexibility (how well the brain can adapt to new situations or rules), which <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892796/">recent research found</a> is associated with OCD. The <a href="http://www.cambridgecognition.com/cantab/cognitive-tests/executive-function/intra-extra-dimensional-set-shift-ied/">CANTAB Intra-Extra Dimensional Shift test (IED)</a>, is another method used to measure OCD severity by testing the cognitive flexibility of OCD sufferers. Understanding the severity of symptoms and levels of cognitive flexibility are important for knowing how well a patient is responding to treatment. </p>
<p>At the moment, treatments for this type of OCD are either <a href="https://academic.oup.com/ijnp/article/21/1/42/4210641">selective serotonin re-uptake inhibitors</a>, such as Prozac or Zoloft, or a type of cognitive behaviour therapy called <a href="https://www.sciencedirect.com/science/article/pii/S1476179306000802">“exposure and response prevention”</a>. During exposure and response prevention therapy, patients are progressively exposed to “contaminated” objects (a toilet seat, for example) until they feel a rise in anxiety. They then avoid performing compulsive behaviours such as excessively and repeatedly washing their hands. This helps the patient experience the decrease of anxiety and overcome their fear, resulting in a less negative reaction to the “contaminated” objects over time. Many patients fail to respond to this treatment – and many <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423997/">may skip therapy</a> because they feel too anxious when thinking about touching contaminated objects. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/246224/original/file-20181119-76150-10z9dpe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/246224/original/file-20181119-76150-10z9dpe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/246224/original/file-20181119-76150-10z9dpe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/246224/original/file-20181119-76150-10z9dpe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/246224/original/file-20181119-76150-10z9dpe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/246224/original/file-20181119-76150-10z9dpe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/246224/original/file-20181119-76150-10z9dpe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Measures of OCD symptoms were taken before and after using the app.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-woman-using-smartphone-on-wooden-588975182?src=zvk4G9RovTqg6uDQwro6dw-1-29">THE YOOTH/ Shutterstock</a></span>
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<p>But therapies using new technology may have the potential to transform OCD treatment. My colleagues and I conducted a <a href="https://www.nature.com/articles/s41598-018-33142-2">recent study</a> using videos accessed via a smartphone app we developed as an alternative to traditional therapies.</p>
<p>We conducted separate tests on three different groups of people using the same smartphone app. Participants in each group watched a prerecorded video of themselves performing different activities. The severity of their OCD symptoms and cognitive flexibility were also measured using the various OCD indices before and after using the app. </p>
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Read more:
<a href="https://theconversation.com/how-ocd-impairs-memory-and-learning-in-children-and-adolescents-and-what-to-do-about-it-91262">How OCD impairs memory and learning in children and adolescents – and what to do about it</a>
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<p>In the first group, participants watched a brief video of themselves washing their hands. Participants in the second group watched footage of themselves repeatedly touching an object which prompted their disgust, such as a toilet bowl. The third group acted as a control, where participants watched themselves performing random hand movements. This video had no therapeutic value and was only used to test the effect of watching a video on the phone. The participants were instructed to use the app four times a day for seven days and their symptoms were measured before and after use of the app.</p>
<p>In the handwashing app group, symptoms of OCD were reduced by 14% and 17% when measured using the OCI-R and YBOCS scales. In the contamination app group, symptoms were reduced by 21% and 25% when measured using the same scales. IED test errors were also reduced by 52%, which showed an increase in participants’ cognitive flexibility. </p>
<p>Aside from these promising results, the participants gave feedback that suggests how important an app could be in treating OCD. One participant of the hand-washing group said: </p>
<blockquote>
<p>If I am commuting, for example on the bus, and touch something contaminated and can’t wash my hands for the next two hours, the app would be a sufficient substitute. </p>
</blockquote>
<p>A participant in the contamination group also commented: </p>
<blockquote>
<p>My contamination and washing tendencies reduced a lot. For example, if I put the rubbish out and touch the bin I would normally wash my hands immediately. But after I started to use the app I felt like it would be silly to wash my hands…</p>
</blockquote>
<p>Using our smartphone app to reduce OCD symptoms in people with contamination fears may be useful to complement existing therapies in patients with an OCD diagnosis. OCD patients could use the app in their own work or home environments or while travelling. With more research, it could also be possible that this app may provide an alternative form of treatment, particularly for OCD patients who have recently developed OCD symptoms, or for those who find it more convenient to use technology. </p>
<p>Unlike standard treatments, tech-based therapies are inexpensive and can make psychotherapy readily available to patients whenever they need it. They can also encourage patients to take a more active role in their treatment. These smartphone treatments can also be individualised to every patient, and may be suitable for developing countries, where <a href="https://www.nature.com/articles/475027a">access to specialised care</a> may not be readily available.</p><img src="https://counter.theconversation.com/content/106485/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Sahakian consults for Cambridge Cognition. She has received funding from the NIHR Cambridge Biomedical Research Centre (Mental Health Theme) and a Wellcome Grant (200181/Z/15/Z).</span></em></p>Technology could be a promising alternative to traditional therapy.Barbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/912622018-02-08T11:49:38Z2018-02-08T11:49:38ZHow OCD impairs memory and learning in children and adolescents – and what to do about it<figure><img src="https://images.theconversation.com/files/205519/original/file-20180208-180844-15o5526.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">OCD can make it hard to concentrate.</span> <span class="attribution"><span class="source">Syda Productions/Shutterstock</span></span></figcaption></figure><p>Imagine feeling like you’re covered in germs that could kill you every time you come home from being in a public space. Before showering, you’d have to get inside without letting anything that’s touched the outside world come into contact with your house. The reality of living with obsessive compulsive disorder can be debilitating, and quite different from what people usually mean when they refer to themselves as being “a bit OCD”.</p>
<p>It is particularly heartbreaking to see children and adolescents suffering from OCD, which is often chronic and tends to continue into adulthood. We have now discovered that OCD in young people actually significantly alters both memory and learning ability.</p>
<p>OCD, which affects <a href="http://www.anxietycare.org.uk/docs/ocdchild.asp">2-3% of people</a> at some point during their life, involves ritualistic behaviour such as constantly checking on things, placing objects in a certain order or washing hands repeatedly. This helps relieve intrusive thoughts in the short term, such as an obsession with things being “just right” or an intense fear of dirt or contamination. The condition can leave some sufferers unable to eat, leave the house or in other ways go about their daily lives, often becoming isolated and depressed as a result.</p>
<p>It is easy to see how disruptive and embarrassing OCD symptoms can be when a child starts attending school. Habitual repetitive checking can significantly delay the amount of time it takes to complete work in school or at home. Even things that should be fun, such as playing with friends, may become stressful if you’re constantly worried about getting messy or you’re scared of touching public play equipment. </p>
<p>Almost 90% of children and adolescents with OCD <a href="https://www.ncbi.nlm.nih.gov/pubmed/12880501">have problems</a> at school, home or socially – with difficulties doing homework and concentrating being the two most common problems. </p>
<h2>Memory and learning</h2>
<p>In our recent study, <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/impaired-cognitive-plasticity-and-goaldirected-control-in-adolescent-obsessivecompulsive-disorder/16CE956454FC3C761A424B0200382E26/share/51813f1dcbd9bb0ec2e357056f6ecd4411b9c0a2">published in Psychological Medicine</a>, we asked 36 adolescents with OCD and 36 healthy adolescent controls to complete two memory tasks to measure learning and cognitive flexibility. Adolescent OCD patients showed significant impairments in both learning and memory.</p>
<p>The participants were also asked to complete a task to assess “goal-directed control”, an ability which helps us be flexible in our thinking and in our solutions to problems. Habits allow us to automatically perform behaviours that do not require planning or organisation, such as changing gears while driving. However, when there is new important information or rapid changes in the environment, we rely on goal-directed control instead. Again, the adolescents with OCD showed significant impairments in such control.</p>
<p>This is supported by functional neuroimaging of patients with OCD demonstrating increased activity in something called the “<a href="https://en.wikipedia.org/wiki/Cortico-basal_ganglia-thalamo-cortical_loop">cortico-striato-thalamo-cortical</a> circuits” in the brain, which are thought to be involved in control.</p>
<p>Sadly, the problems we identified may lead to stress and anxiety in a child, which is already known to promote the habitual behaviour that is so common in OCD – creating a downward spiral. Stress is also known to impair memory. And we know that stress hormone levels increase when children enrol in school.</p>
<p>What’s more, having learning and memory problems in childhood could lower confidence and affect self-esteem, which in turn are <a href="https://ac.els-cdn.com/S0005796707001647/1-s2.0-S0005796707001647-main.pdf?_tid=e6d49828-0b4d-11e8-8105-00000aacb360&acdnat=1517929165_76053c3b5977c69dba1c335f9dab3398">associated with OCD symptoms</a>, especially checking. </p>
<p>While OCD in adults is slightly different from that in children and adolecents, we have found that adults with OCD do have <a href="https://link.springer.com/article/10.1007/s00213-010-1963-z?no-access=true">problems with attention</a>.</p>
<h2>Treatment options</h2>
<p>We know that memory problems can affect the efficacy of psychological treatment including <a href="https://www.ocduk.org/cognitive-behavioural-therapy">cognitive behavioural therapy</a>, which is currently the best way to treat OCD. This involves changing the way you think and behave in small steps. However, if this does not sufficiently alleviate symptoms, a kind of antidepressant (SSRIs) can help.</p>
<p>Actually tackling the learning and memory problems can also help to improve performance in school, as well as self-confidence. We have recently shown that cognitive training using a <a href="http://www.peak.net">game on an iPad</a> <a href="http://rstb.royalsocietypublishing.org/content/370/1677/20140214">can improve memory problems in schizophrenia</a>. However, future studies are needed to determine the exact relationship between the memory problems in OCD and the symptoms.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/204860/original/file-20180205-19944-csiqlk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/204860/original/file-20180205-19944-csiqlk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=483&fit=crop&dpr=1 600w, https://images.theconversation.com/files/204860/original/file-20180205-19944-csiqlk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=483&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/204860/original/file-20180205-19944-csiqlk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=483&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/204860/original/file-20180205-19944-csiqlk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=607&fit=crop&dpr=1 754w, https://images.theconversation.com/files/204860/original/file-20180205-19944-csiqlk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=607&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/204860/original/file-20180205-19944-csiqlk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=607&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">OCD can lead to repeated hand washing.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-washing-hands-sink-977251?src=m11zh7P8VG2FtKcv9BvzPg-1-3">Anita Patterson Peppers/Shutterstock</a></span>
</figcaption>
</figure>
<p>But what can schools do practically to help students with OCD? <a href="https://www.cam.ac.uk/people/anna-conway-morris">Anna Conway Morris</a>, a consultant psychiatrist in Cambridgeshire and coauthor of the study, has recently been working with schools to support adolescents with OCD. She found that children with OCD often write very slowly or cross things out (to get it “just right”). Their handwriting speed should therefore be measured and, if necessary, they should be given additional time for exams or school work. OCD is also associated with lower processing speed – meaning children should be given more time to answer questions orally. They often get “stuck” on tasks and may need a prompt to move to the next task. </p>
<p>It is important to stress that children with OCD can be high achievers if they are given support to overcome their OCD symptoms. Treatment an early stage is really important. OCD often gets better in adulthood and even those who did not do too well at school often do well at university if they are given the right support. </p>
<p>That means that if we can make teachers aware of these learning and memory problems, they can help OCD students realise their full learning potential. Sadly, at present, it takes on average 11 years to diagnose OCD, and treatment starts after that. Who would find that acceptable for a physical disorder such as a heart problem or cancer? As a society we need to consider good mental health as every bit as important as good physical health.</p><img src="https://counter.theconversation.com/content/91262/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Sahakian consults for Cambridge Cognition and PEAK. </span></em></p>Children and adolescents with obsessive compulsive disorder should be offered extra support at school.Barbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/839462017-10-20T01:14:09Z2017-10-20T01:14:09ZHow seeing problems in the brain makes stigma disappear<figure><img src="https://images.theconversation.com/files/189030/original/file-20171005-15464-vaswym.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A pair of identical twins. The one on the right has OCD, while the one on the left does not.</span> <span class="attribution"><span class="source">Brain Imaging Research Division, Wayne State University School of Medicine</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>As a psychiatrist, I find that one of the hardest parts of my job is telling parents and their children that they are not to blame for their illness.</p>
<p>Children with emotional and behavioral problems continue to suffer considerable stigma. Many in the medical community refer to them as “diagnostic and therapeutic orphans.” Unfortunately, for many, access to high-quality mental health care remains elusive.</p>
<p>An accurate diagnosis is the best way to tell whether or not someone will <a href="http://dx.doi.org/10.1002/9781119958338">respond well to treatment</a>, though that can be far more complicated than it sounds.</p>
<p>I have written three textbooks about using medication in children and adolescents with emotional and behavioral problems. I know that this is never a decision to take lightly. </p>
<p>But there’s reason for hope. While not medically able to diagnose any psychiatric condition, dramatic advances in brain imaging, genetics and other technologies are helping us objectively identify mental illness.</p>
<h2>Knowing the signs of sadness</h2>
<p>All of us experience occasional sadness and anxiety, but persistent problems may be a sign of a deeper issue. Ongoing issues with sleeping, eating, weight, school and pathologic self-doubt may be signs of <a href="http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596">depression, anxiety or obsessive-compulsive disorder</a>.</p>
<p>Separating out normal behavior from problematic behavior can be challenging. Emotional and behavior problems can also vary with age. For example, depression in pre-adolescent children <a href="http://dx.doi.org/10.1111/j.1469-7610.1993.tb01094.x">occurs equally in boys and girls</a>. During adolescence, however, depression rates increase much <a href="http://dx.doi.org/10.1177/0743558400154003">more dramatically in girls</a> than in boys.</p>
<p>It can be very hard for people to accept that they – or their family member – are not to blame for their mental illness. That’s partly because there are no current objective markers of psychiatric illness, making it difficult to pin down. Imagine diagnosing and treating cancer based on history alone. Inconceivable! But that is exactly what mental health professionals do every day. This can make it harder for parents and their children to accept that they don’t have control over the situation. </p>
<p>Fortunately, there are now excellent <a href="https://adaa.org/living-with-anxiety/ask-and-learn/screenings">online tools</a> that can help parents and their children screen for <a href="https://www.nimh.nih.gov/health/topics/index.shtml">common mental health issues</a> such as depression, anxiety, panic disorder and more.</p>
<p>Most important of all is making sure your child is assessed by a licensed mental health professional experienced in diagnosing and treating children. This is particularly important when medications that affect the child’s brain are being considered. </p>
<h1>Seeing the problem</h1>
<p>Thanks to recent developments in genetics, neuroimaging and the science of mental health, it’s becoming easier to characterize patients. New technologies may also make it easier to predict who is more likely to respond to a particular treatment or experience side effects from medication. </p>
<p>Our laboratory has used brain MRI studies to help unlock the underlying anatomy, chemistry and physiology underlying OCD. This repetitive, ritualistic illness – while sometimes used among laypeople to describe someone who is uptight – is actually a serious and often devastating behavioral illness that can paralyze children and their families. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/189033/original/file-20171005-9757-kwjovr.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In children with OCD, the brain’s arousal center, the anterior cingulate cortex, is ‘hijacked.’ This causes critical brain networks to stop working properly.</span>
<span class="attribution"><a class="source" href="https://www.frontiersin.org/files/Articles/126375/fnhum-09-00149-HTML/image_m/fnhum-09-00149-g001.jpg">Image adapted from Diwadkar VA, Burgess A, Hong E, Rix C, Arnold PD, Hanna GL, Rosenberg DR. Dysfunctional activation and brain network profiles in youth with Obsessive-Compulsive Disorder: A focus on the dorsal anterior cingulate during working memory. Frontiers in Human Neuroscience. 2015; 9: 1-11.</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Through sophisticated, high-field brain imaging techniques – such as fMRI and magnetic resonance spectroscopy – that have become available recently, we can actually measure the child brain to <a href="https://doi.org/10.3389/fnhum.2015.00149">see malfunctioning areas</a>. </p>
<p>We have found, for example, that children 8 to 19 years old with OCD never get the “<a href="http://dx.doi.org/10.1016/j.pscychresns.2016.12.005">all clear signal</a>” from a part of the brain called the anterior cingulate cortex. This signal is essential to feeling safe and secure. That’s why, for example, people with OCD may continue checking that the door is locked or repeatedly wash their hands. They have striking brain abnormalities that appear to normalize with effective treatment.</p>
<p>We have also begun a pilot study with a pair of identical twins. One has OCD and the other does not. We found brain abnormalities in the affected twin, but not in the unaffected twin. Further study is clearly warranted, but the results fit the pattern we have found in larger studies of children with OCD before and after treatment as compared to children without OCD.</p>
<p>Exciting brain MRI and genetic findings are also being reported in childhood <a href="http://dx.doi.org/10.1093/med/9780195398212.003.0009">depression</a>, <a href="http://dx.doi.org/10.1016/j.psc.2009.05.004">non-OCD anxiety</a>, <a href="http://dx.doi.org/10.1002/9780470479216.corpsy0595">bipolar disorder</a>, <a href="http://dx.doi.org/10.1002/ajmg.b.32542">ADHD</a> and <a href="http://dx.doi.org/10.1016/j.chc.2013.06.004">schizophrenia</a>, among others.</p>
<p>Meanwhile, the field of psychiatry continues to grow. For example, <a href="http://dx.doi.org/10.1016/j.jaac.2009.12.022">new techniques</a> may soon be able to identify children at increased genetic risk for psychiatric illnesses such as <a href="http://dx.doi.org/10.3389/fpsyt.2014.00050">bipolar disorder</a> and <a href="http://dx.doi.org/10.3389/fpsyt.2014.00071">schizophrenia</a>. </p>
<p>New, more sophisticated brain imaging and genetics technology actually allows doctors and scientists to see what is going on in a child’s brain and genes. For example, by using MRI, our laboratory discovered that the <a href="http://dx.doi.org/10.1097/00004583-200009000-00008">brain chemical glutamate</a>, which serves as the brain’s “light switch,” plays a <a href="https://dx.doi.org/10.1521/capn.2010.15.6.6">critical role</a> in childhood OCD.</p>
<h1>What a scan means</h1>
<p>When I show families their child’s MRI brain scans, they often tell me they are relieved and reassured to “be able to see it.” </p>
<p>Children with mental illness continue to face enormous stigma. Often when they are hospitalized, families are frightened that others may find out. They may hesitate to let schools, employers or coaches know about a child’s mental illness. They often fear that other parents will not want to let their children spend too much time with a child who has been labeled mentally ill. Terms like “psycho” or “going mental” remain part of our everyday language. </p>
<p>The example I like to give is epilepsy. Epilepsy once had <a href="https://www.theguardian.com/books/2016/aug/13/i-willed-him-to-wake-up-epilepsy-in-art-and-in-life">all the stigma</a> that mental illness today has. In the Middle Ages, one was considered to be possessed by the devil. Then, more advanced thinking said that people with epilepsy were crazy. Who else would shake all over their body or urinate and defecate on themselves but a crazy person? Many patients with epilepsy were locked in lunatic asylums. </p>
<p>Then in 1924, <a href="https://www.ncbi.nlm.nih.gov/pubmed/16334737">psychiatrist Hans Berger</a> discovered something called the electroencephalogram (EEG). This showed that epilepsy was caused by electrical abnormalities in the brain. The specific location of these abnormalities dictated not only the diagnosis but the appropriate treatment. </p>
<p>That is the goal of modern biological psychiatry: to unlock the mysteries of the brain’s chemistry, physiology and structure. This can help better diagnose and precisely treat childhood onset mental illness. Knowledge heals, informs and defeats ignorance and stigma every time.</p><img src="https://counter.theconversation.com/content/83946/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Rosenberg receives funding from the Children’s Hospital of Michigan Foundation, Detroit, MI, and a grant from the National Institute of Mental Health (R01MH59299).</span></em></p>It can be very hard for people to accept that they – or their family member – are not to blame for their mental illness. Seeing the evidence in a scan can make a difference.David Rosenberg, Professor, Psychiatry and Neuroscience, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/740922017-03-07T10:48:09Z2017-03-07T10:48:09ZBrain scans reveal why it is so difficult to recover from OCD – and hint at ways forward<figure><img src="https://images.theconversation.com/files/159594/original/image-20170306-20739-1x01xvx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Just two more minutes.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hygiene-cleaning-hands-washing-260417144?src=8in9RGZdPWDSX-5p2pxeLQ-1-0">Alexander Raths/Shutterstock</a></span></figcaption></figure><p>We often refer to people who are extremely neat or organised as “<a href="https://theconversation.com/you-cant-be-a-little-bit-ocd-but-your-everyday-obsessions-can-help-end-the-conditions-stigma-49265">a bit OCD</a>”. But the reality of living with obsessive compulsive disorder is a very different and serious matter. </p>
<p>People with the brain disorder struggle greatly with recurrent, intrusive thoughts (obsessions) and unwanted urges to repeat safety-seeking behaviours over and over again (compulsions). Common examples are exaggerated fears of contamination or causing injury – leading to excessive washing or checking. It is easy to see why that causes extreme distress and interferes with everyday life. </p>
<p>In some cases, people with OCD are tormented with agonising taboo thoughts, for example the fear that they will sexually abuse a child even though they have no desire whatsoever to do so. This is coupled with the compulsion to seek reassurance, for example by avoiding children or checking newspapers in case they have been accused. Such people are often too ashamed to disclose their symptoms, worrying about being punished or judged to be “insane”. When listening to such patients it is clear their torment is real, with day after day spent enduring irrational fears and repeating seemingly purposeless behaviours. </p>
<p>A standard treatment for OCD involves exposure and response prevention (ERP). This involves the patient confronting their worst fears while learning to not perform their compulsions. For example, it may include touching a toilet seat and not being allowed to wash your hands. This treatment is often combined with comparatively high doses of selective serotonin re-uptake inhibitor (<a href="https://theconversation.com/selling-sickness-or-dulling-the-pain-the-pros-and-cons-of-antidepressants-1340">SSRI</a>) drugs – typically three times higher than that needed to treat depression. Together this can help many patients with OCD, but far from all. So why is OCD such a debilitating disorder and why can it be so hard to treat? Our new research <a href="https://www.dropbox.com/sh/1fg6nxundcab57m/AAA5-dzhezumvpW7e8VyHHmHa?dl=0.">offers a clue</a> – and some hope for those struggling.</p>
<p><a href="https://www.youtube.com/watch?v=0za3oKruzZs">Naomi Fineberg</a>, who leads a specialist clinic for patients with OCD, sees many for whom daily life is difficult and who continue to struggle with their disorder despite treatment. According to her, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27235689?report=abstract">about 40% of patients</a> fail to respond to individually-tailored treatments. What’s more, many are left with residual troublesome symptoms such as continuing obsessive thoughts or relapse. </p>
<p>Such patients may still fall into depression and suicidal behaviour after treatment, becoming so overwhelmed by their obsessive compulsive behaviours that they end up neglecting their family, work, friends and health. OCD in its most severe form disrupts even the most basic self-care activities, such as eating or drinking – sometimes resulting in the need for long-term hospitalisation or residential care.</p>
<h2>OCD on the brain</h2>
<p>The new study from our team here at the University of Cambridge, <a href="http://m.pnas.org/content/early/2017/02/28/1609194114.abstract">published in the Proceedings of the National Academy of Sciences</a>, is now beginning to show why this is. We compared 43 OCD patients with 35 healthy control participants in an experiment designed to investigate why patients with OCD struggle to learn that not performing their safety behaviours is in fact “safe”. We did this by examining their ability to flexibly adjust their reactions to changes in threat while inside an fMRI scanner, which measures brain activity by tracking changes in blood flow, at the <a href="http://www.wbic.cam.ac.uk/">Wolfson Brain Imaging Centre</a>. </p>
<p>We showed the participants two angry faces, of which one was sometimes paired with a mild electric shock to the wrist, making it threatening. Recordings of tiny changes in sweat indicated when participants were expecting a shock. To test flexible updating of threat we also reversed the stimuli so that the “safe” face became the threatening one and vice versa. The experiment tests the individual’s ability to learn when a stimulus is safe and so not to expect a shock. By reversing the stimuli, we introduced ambiguity as both faces had by then been associated with the possibility of a shock.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/159599/original/image-20170306-20753-15vikqg.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/159599/original/image-20170306-20753-15vikqg.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=930&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159599/original/image-20170306-20753-15vikqg.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=930&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159599/original/image-20170306-20753-15vikqg.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=930&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159599/original/image-20170306-20753-15vikqg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1169&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159599/original/image-20170306-20753-15vikqg.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1169&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159599/original/image-20170306-20753-15vikqg.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1169&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ventromedial prefrontal cortex: signals safety.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Ventromedial_prefrontal_cortex.png">Brain_human_sagittal_section.svg: Patrick J. Lynch, medical illustrator</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Patients with OCD could initially learn which face predicted threat. But once this had been reversed they were unable to differentiate between the new and the old threatening stimulus – they treated both as threatening. We think this is because they never really learned that one of the faces was truly safe – something which was reflected in their brain activity. Unlike in the healthy participants, there was no signal from the OCD patients’ ventromedial prefrontal cortex, a brain area <a href="http://www.nature.com/npp/journal/v39/n3/full/npp2013191a.html">that normally signals safety</a>.</p>
<p>The results suggest that OCD patients are likely to have difficulty learning when situations are safe in everyday life – and that this has to do with differences in the brain. This has great relevance for the current psychological treatment of OCD, in which patients are expected to learn that not performing excessive and compulsive safety behaviours is in fact “safe” and therefore unnecessary. Current exposure therapies may only teach patients how to deal with their compulsions rather than truly learning that the situations they are so scared of are not actually dangerous. This means that obsessive thoughts can persist, and that it is possible for compulsive behaviour to return in future stressful situations.</p>
<p>The research follows another recent study <a href="http://www.biologicalpsychiatryjournal.com/article/S0006-3223(16)32670-1/abstract">published in Biological Psychiatry</a>, which discovered a lack of communication between specific brain areas in patients with OCD. In particular, it found disrupted connectivity between neural pathways that connect the front of the brain with the basal ganglia, which are critical for flexible thinking and goal-directed behaviours that we know are impaired in OCD patients and are likely to contribute to the difficulty of overcoming the drive to perform needless compulsions.</p>
<p>An avenue for improving future treatment for OCD would be to explore better learning in patients that not performing compulsive safety behaviours is truly safe. This could be achieved by boosting rewards in therapy for not performing safety behaviour or possibly with the help of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006201/">certain drugs</a> that can enhance the positive experience of not having to perform the compulsions.</p><img src="https://counter.theconversation.com/content/74092/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annemieke Apergis-Schoute does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research shows that the brains of people with OCD prevent them from learning that something is safe.Annemieke Apergis-Schoute, Post-doctoral Researcher in Neuroscience, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/492652015-10-19T05:12:37Z2015-10-19T05:12:37ZYou can’t be ‘a little bit OCD’ but your everyday obsessions can help end the condition’s stigma<figure><img src="https://images.theconversation.com/files/98676/original/image-20151016-25112-djsrc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Everyday obsessions</span> <span class="attribution"><span class="source">Janine/Flickr</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>“I’m a little bit OCD” is a phrase that’s often bandied around. Perhaps you’ve used it to describe your excessive cleaning habits or desire for order. Some argue that the flippant use of this phrase trivialises a serious condition and increases stigma. It certainly doesn’t help our understanding of the problem. But denying the obsessive-compulsive experiences that we all have may actually be increasing stigma and preventing those who are suffering from seeking help.</p>
<p><a href="http://www.nhs.uk/conditions/Obsessive-compulsive-disorder/Pages/Introduction.aspx">Obsessive-compulsive disorder</a> (OCD) is a debilitating condition characterised by unwanted intrusive thoughts and repetitive behaviours or mental acts. Although OCD is often associated with cleanliness and orderliness, it can manifest in a variety of ways. Some spend hours each day worrying about whether they have committed a <a href="http://www.ocdaction.org.uk/community/personal-stories/my-ocd-story-living-intrusive-sexual-thoughts-rosebretecher">paedophilic act</a> while others <a href="http://www.theguardian.com/lifeandstyle/2014/apr/04/living-with-ocd-david-adam">are plagued</a> by the thought that they may have caught HIV from their toothbrush, towel or phone.</p>
<p>Roughly <a href="http://www.ncbi.nlm.nih.gov/pubmed/15939837">one in 50</a> people are diagnosed with OCD after being assessed by a mental health professional and meeting <a href="http://beyondocd.org/information-for-individuals/clinical-definition-of-ocd">certain criteria</a>. This diagnostic system means you’re either regarded as having OCD or not. As a result, some view OCD as an illness <a href="http://www.ocdni.co.uk/fixers/4584812214">and argue</a> that saying you’re a “little bit OCD” is akin to saying you’re having “a little bit of a heart attack” or you’re “a little bit pregnant” - it’s impossible. <a href="http://www.ocduk.org/are-you-little-bit-ocd">Others argue</a> that the phrase increases stigma in those with a diagnosis.</p>
<h2>Everyday obsessions and compulsions</h2>
<p>There is no denying that individuals diagnosed with OCD are often <a href="http://www.time-to-change.org.uk/category/blog/ocd">affected by stigma</a>. But <a href="http://www.ncbi.nlm.nih.gov/pubmed/23831861">research actually suggests</a> that considering mental health problems as biological “disorders” that are either present or absent actually increases some negative views, such as increasing the belief that people with mental health problems are dangerous and less likely to recover. </p>
<p>When considering OCD as a diagnostic label, it’s true that you cannot be “a little bit OCD”. The constant misuse of this phrase may reflect our <a href="http://www.theguardian.com/media/mind-your-language/2014/jun/19/mind-your-language-hyperbole">tendency for hyperbole</a> as much as it reflects our ignorance about the condition. But this does not mean that thoughts and behaviours that are characteristic of OCD are exclusive to those with a diagnosis. </p>
<p>Have you ever had the sudden impulse to push somebody in front of a train? Or suddenly doubted whether you had locked your front door? These are examples of intrusive thoughts and they are experienced <a href="http://jonabram.web.unc.edu/files/2015/01/IITIS-Part-1-2014.pdf">almost universally</a>.</p>
<p>Although these thoughts are unwanted, for many of us they are infrequent and don’t bother us very much. For others, they are more common and troublesome. Roughly one in three people with no diagnosed mental health issue report having been bothered by intrusive thoughts <a href="http://www.ncbi.nlm.nih.gov/pubmed/19188283">for periods of over two weeks</a>. And for the million people diagnosed with OCD in the UK, these thoughts are so frequent and upsetting that they can prevent them from living an ordinary life.</p>
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<span class="caption">Did I leave the gas on?</span>
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<p>Another experience that you may be familiar with is the need for order, neatness or getting things “just right”. Perhaps you feel uncomfortable if books are not arranged in size order. Or feel your hands are not quite clean enough unless you wash them several times. </p>
<p>These are examples of “<a href="http://www.ncbi.nlm.nih.gov/pubmed/12732376">not just right experiences</a>”, the general feeling that something is not as it should be. These are <a href="http://www.ncbi.nlm.nih.gov/pubmed/12732376">common experiences</a> and most of you reading this article will have likely had the experience at least once in the past week. Again though, for most people these experiences are not a problem. For others they are more frequent and upsetting. And for those with a diagnosis of OCD the feelings can be relentless and <a href="http://www.ncbi.nlm.nih.gov/pubmed/20627224">extremely upsetting</a>.</p>
<p>The thoughts and behaviours that are characteristic of OCD exist on a continuum. In fact, much of what we know about OCD has been discovered from research on people from the <a href="http://www.ncbi.nlm.nih.gov/pubmed/24561743">general population</a>.</p>
<p>It is inaccurate and unhelpful to compare the presence of OCD to the presence of a heart attack. OCD is more akin to blood pressure or acne. Most of us know what it’s like to have a pimple. Very few of us know what it’s like to have <a href="http://www.webmd.com/skin-problems-and-treatments/cystic-acne">cystic acne</a>. Crucially though, we can empathise with those who have cystic acne by imagining “what if?”. What would it be like if I had lots more pimples? What if they were larger, more visible and more painful? How would this affect me? </p>
<h2>Now imagine you couldn’t get it to stop</h2>
<p>Accepting the experiences we share can serve to increase our understanding and empathy, not reduce it. As David Adam suggests in his <a href="http://www.theguardian.com/books/2014/apr/20/the-man-who-couldnt-stop-review-david-adam-ocd-review">OCD memoir</a>, the most helpful response to somebody saying “I’m a little bit OCD”, might be “now imagine you couldn’t get it to stop”.</p>
<p>Mental health education needs to <a href="https://petition.parliament.uk/petitions/104545">begin in schools</a> at the time when children may begin to have problems with troublesome <a href="http://www.ncbi.nlm.nih.gov/pubmed/19188283">thoughts and behaviours</a>. And campaigns such as that by the <a href="http://www.ocduk.org/ocd-awareness-week-2015">charity OCD-UK</a> are vital in increasing the public’s understanding of OCD.</p>
<p>But more importantly, we all need to talk openly and sensitively about our irrational thoughts and behaviours. Roughly two thirds of <a href="http://ac.els-cdn.com/S2211364913000730/1-s2.0-S2211364913000730-main.pdf?_tid=fc5192c6-5701-11e5-a795-00000aacb360&acdnat=1441810354_073c0cd3e622e8c476b527a8a96bf46b">people with OCD</a> will never seek treatment. Many feel shame for having strange or taboo thoughts. Perhaps if they knew that we were all having them too, they would feel more comfortable talking to somebody about theirs.</p><img src="https://counter.theconversation.com/content/49265/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Connor Heapy does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Saying you’re ‘a little bit OCD’ isn’t helpful, but neither is denying the experiences we share.Connor Heapy, PhD student in Clinical Psychology, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.