tag:theconversation.com,2011:/africa/topics/obsessive-compulsive-disorder-3544/articlesObsessive-compulsive disorder – The Conversation2024-01-23T16:34:21Ztag:theconversation.com,2011:article/2213762024-01-23T16:34:21Z2024-01-23T16:34:21ZPeople with OCD are more likely to die earlier, of any cause<figure><img src="https://images.theconversation.com/files/570860/original/file-20240123-21-eh39uf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7578%2C4263&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/obsessive-compulsive-disorder-arranging-paperclips-row-2025295895">Microgen/Shutterstock</a></span></figcaption></figure><p>People with <a href="https://www.nhs.uk/mental-health/conditions/obsessive-compulsive-disorder-ocd/overview/">obsessive-compulsive disorder</a>, or OCD for short, are 82% more likely to die earlier – from natural or unnatural causes – than people without the condition, a <a href="https://www.bmj.com/content/384/bmj-2023-077564.full">new study</a> reveals.</p>
<p>Previous studies have found <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2484488">excess deaths</a> in people with OCD, but the specific causes of death had been poorly researched – maybe with the exception of suicide. Notably, people with OCD have <a href="https://www.nature.com/articles/mp2016115">similar suicide rates</a> to people with other mental health disorders.</p>
<p>OCD affects about <a href="https://www.psychiatry.org/patients-families/obsessive-compulsive-disorder/what-is-obsessive-compulsive-disorder">2% of the population</a>. People with the condition have distressing intrusive and repetitive thoughts (such as a fear of being contaminated or becoming aggressive towards others) and feel compelled to perform time-consuming rituals to reduce the discomfort caused by the thoughts, such as cleaning, repeating or checking. </p>
<p>The disorder significantly impairs daily life, affecting relationships, social activities and the general ability to function. </p>
<p>My colleagues and I at the Karolinska Institutet in Sweden <a href="https://www.bmj.com/content/384/bmj-2023-077564.full">aimed to understand</a> the specific natural and unnatural causes of death contributing to the reported elevated mortality rates in OCD. We used Swedish population registers, which include administrative and healthcare data from the whole population, to compare a group of 61,378 people who had received a diagnosis of OCD with 613,780 people without OCD. </p>
<p>We followed both groups for more than four decades (from 1973 to 2020) and found that people with OCD died at an earlier average (mean) age than those without OCD (69 v 78 years). </p>
<p>The risk of death during the study period was 82% higher in the group with OCD, compared to the group without OCD. The increased risk of death was attributable to both natural (31% increased risk) and unnatural causes (230% increased risk).</p>
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<figcaption><span class="caption">OCD explained.</span></figcaption>
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<h2>Specific causes</h2>
<p>For the first time, we were able to identify specific causes of death due to natural causes. People with OCD had increased risks due to lung diseases (73%), mental and behavioural disorders (58%), diseases of the urinary and reproductive organs (55%), endocrine, nutritional and metabolic diseases (47%), diseases of the blood vessels (33%), nervous system (21%) and digestive system (20%). </p>
<p>Intriguingly, the risk of death due to cancer was 13% lower in those with OCD. The reason this risk goes in the opposite direction is not known. </p>
<p>Among the unnatural causes of death, suicide was the main contributor to the increased mortality. Those with OCD, compared to those without, had a nearly fivefold increased risk of dying by suicide. Also, people with OCD had a 92% increased risk of dying due to accidents, including traffic accidents or falls. </p>
<p>The results held even after we took mental health disorders other than OCD – for example, anxiety, depression and substance use disorders – into account. </p>
<p>Also, when we compared the OCD group with their siblings without OCD, the results remained largely unchanged. This confirms that our results cannot only be attributed to any accompanying mental health disorders or genetic or environmental factors shared between families, but that are likely to be related to OCD itself. </p>
<h2>Mostly preventable</h2>
<p>Although these are not positive findings for people with OCD, it’s important to note that the proportion of people dying of each cause was relatively small, even if compared with the group without OCD it translated to a higher risk. </p>
<p>For example, during the study period, 2.5% of people with OCD died due to circulatory system diseases (such as heart attacks and strokes), which is a low percentage. Nonetheless, this percentage is higher than the 1.8% of deaths by this cause in the group without OCD. </p>
<p>Even so, it is not acceptable that people with OCD have to face these extra risks. I hope that these results spur healthcare professionals into action and contribute to people with OCD receiving better care. </p>
<p>Importantly, most of the causes of death that showed an increased risk are related to non-communicable diseases (for example, cardiovascular diseases, diabetes, chronic lung diseases, mental disorders, neurological disorders) and to external causes (for example, suicide, accidents), which can be classified as preventable. </p>
<p>People with OCD need to be aware of these risks. This may motivate behavioural changes – such as getting more exercise and having a healthy diet – that can play a role in preventing ill health and early death.</p><img src="https://counter.theconversation.com/content/221376/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span><a href="mailto:lorena.fernandez.de.la.cruz@ki.se">lorena.fernandez.de.la.cruz@ki.se</a> has received funding from the Swedish Research Council for Health, Working Life and Welfare (FORTE), Region Stockholm (ALF funding), the Swedish Society of Medicine (Svenska Läkaresällskapets), and Karolinska Institutet. She also receives royalties for contributing articles to UpToDate and Wolters Kluwer Health and for editorial work from Elsevier, outside the submitted work.</span></em></p>People with OCD have a 31% increased risk of death from natural causes and a 230% increased risk of death from unnatural causes compared to those without the disorder.Lorena Fernández de la Cruz, Clinical Researcher, Psychiatric Epidemiology, Karolinska InstitutetLicensed 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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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">
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<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>
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<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>
<figure class="align-center zoomable">
<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>
<figcaption>
<span class="caption"></span>
<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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<span class="caption"></span>
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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/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/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>
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<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><em>You can listen to more articles from The Conversation, narrated by Noa, <a href="https://theconversation.com/us/topics/audio-narrated-99682">here</a>.</em></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/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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<p>
<em>
<strong>
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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</em>
</p>
<hr>
<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>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"973635337380614144"}"></div></p>
<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>
<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>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">
<figcaption>
<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>
</figcaption>
</figure>
<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>
<hr>
<p>
<em>
<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>
</strong>
</em>
</p>
<hr>
<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/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>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<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">
<figcaption>
<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>
</figcaption>
</figure>
<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/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/1385172020-05-25T06:35:25Z2020-05-25T06:35:25ZCoronavirus lockdown made many of us anxious. But for some people, returning to ‘normal’ might be scarier<figure><img src="https://images.theconversation.com/files/336313/original/file-20200520-152284-e1ck4d.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5354%2C3577&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>Many Australians have welcomed the gradual easing of coronavirus restrictions. We can now catch up with friends and family in small numbers, and get out and about a little more than we’ve been able to for a couple of months.</p>
<p>All being well, restrictions will continue to be lifted in the weeks and months to come, allowing us slowly to return to some kind of “normal”.</p>
<p>This is good news for the economy and employment, and will hopefully help ease the high levels of <a href="https://psychology.anu.edu.au/research/projects/australian-national-covid-19-mental-health-behaviour-and-risk-communication-survey">distress and mental health problems</a> our community has been experiencing during the pandemic.</p>
<p>For some people, however, the idea of reconnecting with the outside world may provoke other anxieties.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/7-ways-to-manage-your-coronaphobia-138120">7 ways to manage your #coronaphobia</a>
</strong>
</em>
</p>
<hr>
<h2>Social distancing and mental health</h2>
<p>We <a href="https://psychology.anu.edu.au/research/projects/australian-national-covid-19-mental-health-behaviour-and-risk-communication-survey">surveyed</a> a <a href="http://methods.sagepub.com/Reference/encyclopedia-of-survey-research-methods/n469.xml">representative sample</a> of Australian adults at the end of March, about a week after restaurants and cafes first closed, and with gatherings restricted to two people. </p>
<p>Even at this early stage, it was clear levels of depression and anxiety were much higher than usual in the community.</p>
<p>Surprisingly, exposure to the coronavirus itself had minimal impact on people’s mental health. We found the social and financial disruption caused by the restrictions had a much more marked effect. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/not-all-doom-and-gloom-even-in-a-pandemic-mixed-emotions-are-more-common-than-negative-ones-138014">Not all doom and gloom: even in a pandemic, mixed emotions are more common than negative ones</a>
</strong>
</em>
</p>
<hr>
<p>Many people in our survey reported the restrictions also benefited them in some way. Around two-thirds of people listed at least one positive impact coronavirus has had on them, such as spending more time with family. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/337243/original/file-20200525-124860-1kidie1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/337243/original/file-20200525-124860-1kidie1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/337243/original/file-20200525-124860-1kidie1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/337243/original/file-20200525-124860-1kidie1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/337243/original/file-20200525-124860-1kidie1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/337243/original/file-20200525-124860-1kidie1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/337243/original/file-20200525-124860-1kidie1.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">For many people, lockdown has been an opportunity to enjoy more time with family.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Another positive thing we’ve seen is communities coming together in new ways. For instance, teddy bears have appeared in windows for neighbourhood children to find, with <a href="https://www.facebook.com/groups/659529201540181/">We’re Going On a Bear Hunt Australia</a> connecting more than 20,000 followers on Facebook.</p>
<p>More than half of our survey respondents were hopeful “society will have improved in one or more ways” after the pandemic.</p>
<h2>Adjusting to the ‘new normal’</h2>
<p>Our findings show adverse events can affect mental health and well-being in unanticipated and mixed ways.</p>
<p>Because we haven’t experienced anything like the coronavirus pandemic in recent history, we simply don’t know how our community will readjust as restrictions ease.</p>
<p>Some people may feel particularly anxious about reconnecting. For example, people with social anxiety might experience heightened anxiety about the prospect of socialising again.</p>
<p>One of the main evidence-based treatments for social anxiety is <a href="https://guilfordjournals.com/doi/abs/10.1521/ijct.2008.1.2.94">exposure</a> therapy. When social exposure is reduced, as has been the case over the last couple of months, social anxiety may flare up, making returning to social gatherings particularly daunting.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-is-stressful-here-are-some-ways-to-cope-with-the-anxiety-133146">Coronavirus is stressful. Here are some ways to cope with the anxiety</a>
</strong>
</em>
</p>
<hr>
<p>Meanwhile, people who fear germs, such as some people with obsessive compulsive disorder (OCD), might worry about re-entering public spaces. </p>
<p>Even people who don’t normally have these tendencies might share similar worries. Our survey found around half of Australians were at least moderately concerned about becoming infected with COVID-19.</p>
<p>People who experienced psychological conditions before the pandemic may be able to draw on skills they’ve learned through therapy to help them re-engage. But people without any prior experience of anxiety or depression could struggle more because they have never had to manage these conditions before.</p>
<h2>Tips for people who are feeling anxious</h2>
<p>Whether you have previously experienced anxiety or not, there are several strategies you can use to manage your worries around re-engaging. </p>
<p>One <a href="https://www.tandfonline.com/doi/abs/10.1080/16506073.2016.1231219">effective</a> psychological approach to managing anxiety is cognitive behavioural therapy (CBT). </p>
<p>CBT involves learning about how your thoughts affect your mood, and developing strategies to manage problematic thinking patterns. Importantly, CBT can be <a href="https://www.tandfonline.com/doi/full/10.1080/16506073.2017.1401115">effectively delivered online</a>.</p>
<p>CBT might also include developing a social or germ “exposure hierarchy”. For instance, working up from seeing a few people briefly to longer interactions, with more people. There are some critical ingredients that make exposure therapy work though, so it’s important to get advice from a <a href="https://www.psychology.org.au/Find-a-Psychologist">psychologist</a> or follow an <a href="https://beacon.anu.edu.au/">evidence-based online program</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336327/original/file-20200520-152284-lyex93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336327/original/file-20200520-152284-lyex93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336327/original/file-20200520-152284-lyex93.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336327/original/file-20200520-152284-lyex93.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336327/original/file-20200520-152284-lyex93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336327/original/file-20200520-152284-lyex93.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336327/original/file-20200520-152284-lyex93.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">If you’re feeling anxious about coming out of your isolation bubble, you’re probably not the only one.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848393/">Mindfulness</a>, regular <a href="https://bjsm.bmj.com/content/48/3/187.short">exercise</a> and getting enough <a href="https://doi.org/10.1016/j.smrv.2018.10.006">sleep</a> can also help manage anxiety.</p>
<p>If you or someone you know is feeling distressed, it may also be helpful to contact relevant support services in your area – many of which now have telehealth options. </p>
<p>These may include your GP or a <a href="https://www.psychology.org.au/Find-a-Psychologist">psychologist</a>, or community services like <a href="https://www.lifeline.org.au/">Lifeline</a>, <a href="https://www.sane.org">SANE Australia</a>, or <a href="https://www.beyondblue.org.au/">Beyond Blue</a>.</p>
<h2>Things are likely to change over time</h2>
<p>The public health measures implemented to mitigate coronavirus risk have worked to stop the spread of the virus, but they’ve also disrupted the way we live. </p>
<p>There’s much speculation on what the future will look like, resulting in the “new normal” terminology. A key concern as we continue to navigate this new normal is our collective mental health.</p>
<p><a href="https://www.theguardian.com/world/2020/may/14/japan-suicides-fall-sharply-as-covid-19-lockdown-causes-shift-in-stress-factors">Japan</a> experienced a 20% decrease in suicides in April 2020 relative to April 2019. Yet predictive <a href="https://www1.racgp.org.au/newsgp/clinical/calls-for-urgent-attention-to-covid-related-mental">modelling raises concerns</a> about suicide rates potentially rising after the pandemic recedes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-isolation-a-feeling-138009">Is isolation a feeling?</a>
</strong>
</em>
</p>
<hr>
<p>But it’s important to remember no model can perfectly predict the complex impacts of this unprecedented pandemic. </p>
<p>We’ll need ongoing data collection to assess how community mental health is faring over the coming months. And we’ll need to use this data to implement <a href="https://www.ncbi.nlm.nih.gov/pubmed/16719673">evidence-based</a> mental health strategies and policies as and when they’re needed.</p><img src="https://counter.theconversation.com/content/138517/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Dawel receives funding from The Australian National University. </span></em></p><p class="fine-print"><em><span>Eryn Newman receives funding from The Australian National University. </span></em></p><p class="fine-print"><em><span>Sonia McCallum receives funding from The Australian National University.</span></em></p>Particularly for people with social anxiety, the prospect of reconnecting with the outside world could be daunting. But there are things you can do to make the transition a little easier.Amy Dawel, Clinical psychologist and lecturer, Australian National UniversityEryn Newman, Lecturer, Research School of Psychology, Australian National UniversitySonia McCallum, Postdoctoral Fellow, Research School of Population Health, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1335772020-03-31T11:49:38Z2020-03-31T11:49:38ZExercise addiction is a real mental health condition, yet still poorly understood<figure><img src="https://images.theconversation.com/files/324224/original/file-20200331-65518-abzhm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7360%2C4912&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with exercise addiction might feel withdrawal symptoms if they don't exercise.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-shoes-womans-muscular-legs-feet-763881706">Sorapop Udomsri/ Shutterstock</a></span></figcaption></figure><p>We might assume a person that goes to the gym every day is “addicted” to exercise. But in reality, exercise addiction is a complicated condition that researchers still don’t fully understand.</p>
<p>Exercise addiction is different from going to the gym or for a run everyday. Rather, the <a href="https://www.bmj.com/content/357/bmj.j1745">condition</a> is characterised by an obsessive or compulsive need to exercise, to the detriment of quality of life. For example, a person with the condition might skip a friend’s wedding because they “need” to train. </p>
<p>Exercise addicts also experience strong withdrawal symptoms and train through injury, rather than following medical advice. One example of this is the case of <a href="https://www.bbc.co.uk/news/uk-51294715?fbclid=IwAR0p0i8l0u18IUFlHndTIRqtoXY5Y-BPIdpmfsFu6kNfDlN54C8ij73X0ZI">Hope Virgo</a>, who exercised so much and ate so little that she had a calcium deficiency, causing her to break bones while exercising.</p>
<p>Key symptoms of exercise addiction generally include:</p>
<ul>
<li>Feeling a compulsion to do more and more exercise, or feeling that you’re not doing enough</li>
<li>Training through injury</li>
<li>Feeling strong withdrawal symptoms if exercise is stopped</li>
<li>Missing important social events because you “have to” exercise.</li>
</ul>
<p>Exercise addiction is not currently recognised by either the World Health Organization or the American Psychiatric Association due to a lack of research on the condition. However there’s a <a href="https://www.sciencedirect.com/science/article/pii/S0306460318308633">growing body of research</a> exploring exercise addiction.</p>
<p>How common the issue is seems to vary significantly between different types of exercise. It’s estimated that between <a href="https://www.sciencedirect.com/science/article/pii/S1469029212000829">0.3-0.5%</a> of the total population (including people who don’t exercise) are at risk of exercise addiction. In people who exercise regularly, between <a href="https://link.springer.com/article/10.1007/s40279-018-1011-4">3-7% of people</a> are at risk of developing exercise addiction. However, we can’t be sure how accurate these numbers are as there’s currently no universally accepted diagnostic criteria for exercise addiction.</p>
<h2>Complicated diagnosis</h2>
<p>As such, current tools to diagnose exercise addiction assess a person’s risk by using an educated guess of what to measure. Some tools are based on medical <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767415/">diagnostic criteria for substance</a> abuse, while others compare symptoms against the experiences of self-defined “exercise addicts”. This means that different methods of measuring exercise addiction are reporting on different things, which makes it pretty hard to say how common it really is. </p>
<p>Complicating matters further is the athlete paradox. Professional athletes train a lot – typically more than the average gym enthusiast. They definitely have to make sacrifices, often impacting their quality of life because of it – for example, they probably miss social events for training at times.</p>
<p>But if you ask them to analyse their own behaviour, they will often tell you they are just following their training schedule, that they have no choice. Athletes would therefore score highly on standard exercise addiction questionnaires.</p>
<p>Exercise addiction has also been shown to be linked to eating disorders, with a <a href="https://link.springer.com/article/10.1007/s40519-019-00842-1">recent study</a> showing that people with eating disorders are 3.7 times more likely to have exercise addiction. In fact, “excessive exercise” is part of the diagnostic criteria for both <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221424/pdf/Dtsch_Arztebl_Int-108-0678.pdf">bulimia and anorexia</a>. This is because people with eating disorders look to find ways to lose weight, and exercise is one way to burn calories.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/324227/original/file-20200331-65518-b8ew29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324227/original/file-20200331-65518-b8ew29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324227/original/file-20200331-65518-b8ew29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324227/original/file-20200331-65518-b8ew29.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324227/original/file-20200331-65518-b8ew29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324227/original/file-20200331-65518-b8ew29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324227/original/file-20200331-65518-b8ew29.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">Exercise addiction has been linked to other mental health conditions, including anorexia and body dysmorphic disorder.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-detail-girl-weighing-herself-84311326">Monkey Business Images/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Links have also been found between body <a href="https://www.nhs.uk/conditions/body-dysmorphia/">dysmorphic disorder</a> (also known as body dysmorphia) and exercise addiction. Body dysmorphic disorder is an anxiety disorder in which a person might obsess over one or more perceived flaws in their appearance. This link suggests that negative body image might be intrinsically linked to exercise addiction. </p>
<p>There are also links between exercise addiction, eating disorders and <a href="https://www.nhs.uk/conditions/obsessive-compulsive-disorder-ocd/">obsessive-compulsive disorder</a> (OCD). People with OCD demonstrate many of the same traits that are present in both exercise addiction and eating disorders such as a lack of control over a compulsion, such as exercise. This shows that exercise addiction could simply be another form of OCD.</p>
<p>Some researchers have argued that exercise addiction does not exist if <a href="https://bjsm.bmj.com/content/bjsports/34/6/423.full.pdf">another disorder</a> isn’t present. Yet the <a href="https://www.apa.org/pubs/books/4311538">majority of research</a> on exercise addiction doesn’t screen for primary conditions like eating disorders or body dysmorphic disorder – instead they only looks for signs of exercise addiction.</p>
<p>This means that we just don’t know whether or not exercise addiction is an independent condition or simply a symptom of something else. Future research should try focusing on screening for other disorders when looking at exercise addiction to see whether or not this condition exists if other conditions – like eating disorders – aren’t present.</p>
<p>Current treatments for potential exercise addiction can include <a href="https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/">cognitive behavioural therapy</a>, although its <a href="https://www.tandfonline.com/doi/abs/10.1080/1606635021000032366">efficacy is questionable</a> as limited studies have been conducted. When it comes to treatment, it’s important to determine if exercise addiction is the primary condition, or whether it is a symptom of something else. If it’s a symptom of another condition, treating the primary condition should be the priority.</p><img src="https://counter.theconversation.com/content/133577/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>Exercise addiction describes an obsessive or compulsive need to exercise – even when you’re injured.Mike Trott, PhD candidate, Centre for Sport and Exercise Sciences, Anglia Ruskin UniversityLee Smith, Reader in Physical Activity and Public Health, Anglia Ruskin UniversityLicensed 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>
<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>
<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">
<figcaption>
<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>
</figcaption>
</figure>
<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>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<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/570572016-05-15T19:47:50Z2016-05-15T19:47:50ZFear of death underlies most of our phobias<figure><img src="https://images.theconversation.com/files/120926/original/image-20160503-19512-x821j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some people focus their fear of death on smaller and more manageable threats.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/pimthida/5418964298/in/photolist-9fRBhW-5zeB54-6otJia-9eyFvf-63Kkd4-4wgp5g-5JyLGJ-63jHR-49L188-5jhvWc-6EAERh-dVGK3L-cyob43-oPD7kt-pjQTT-pyDRL-6PsDnM-x11QJ6-5pCwdV-8A8Mku-24CpzJ-wGs6a3-5RhNyi-4n81L5-dUpKDY-3PxNn-aRN7fT-5oYpoD-4BZZhD-saYoQz-dudTZ5-9WdKwK-b8ALTR-4pSDhX-edWwLF-opWGzz-2KNNJZ-iMzU6e-mbDwqv-iMzXfk-4vZzNp-4ai2Sq-7pAyAs-qBLqtr-6L3ZrL-nF9nvU-AiLRb-9C55VB-iMzXFF-iMACCE">Pimthida/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>This is the first in our <a href="https://theconversation.com/au/topics/coping-with-mortality">Coping with Mortality</a> series, which looks at fear of death across the ages and how to cope with the dying process. Read the next article on helping children process death <a href="https://theconversation.com/adults-can-help-children-cope-with-death-by-understanding-how-they-process-it-58057">here</a>.</em></p>
<hr>
<p>Awareness of our mortality is part of being human. As author and existential philosopher <a href="https://mafhom.files.wordpress.com/2012/11/staring-at-the-sun-yalom.pdf">Irvin Yalom said</a>, we are “forever shadowed by the knowledge that we will grow, blossom and, inevitably, diminish and die”. </p>
<p>There is growing <a href="http://psycnet.apa.org/books/13748/001">research exploring</a> the overwhelming anxiety that the inevitability of death, and our uncertainty about when it will occur, has the power to create. A social psychological theory, called <a href="http://web.missouri.edu/%7Esegerti/capstone/Arndt.pdf">terror management theory (TMT)</a>, is one way to understand how this anxiety influences our behaviour and sense of self. </p>
<h2>Coping mechanisms</h2>
<p>According to this theory, we manage our fear of death by creating a sense of permanence and meaning in life. We focus on personal achievements and accomplishments of loved ones; we take endless photos to create enduring memories; and we may attend church and believe in an afterlife. </p>
<p>These behaviours bolster our self-esteem and can help us feel empowered against death. For some, however, periods of stress or threats
to their health, or that of loved ones, <a href="https://books.google.com.au/books/about/The_Psychology_of_Death.html?id=dMfC9N2BoDAC">may result in ineffective and pathological</a>
coping mechanisms.</p>
<p>These people might <a href="http://www.tandfonline.com/doi/abs/10.1080/08873267.2012.732155">focus their real fear of death</a> on smaller and more manageable threats, such as spiders or germs. Such phobias may appear safer and more controllable than the ultimate fear of death.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?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">We might take endless photographs to create a sense of permanence.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1442507210693-938e0e77fef2?ixlib=rb-0.3.5&q=80&fm=jpg&crop=entropy&s=cfd25c0a66804cec5e2d5b6eee7af581">Annie Spratt/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This makes sense because when we <a href="http://www.sciencedirect.com/science/article/pii/S0272735814001354">look closely at the symptoms</a> of several anxiety-related disorders, death themes feature prominently. </p>
<p>When children experience separation anxiety disorder, it is <a href="http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596">often connected to excessive fear</a> of losing major attachment figures – such as parents or other family members – to harm or tragedy from car accidents, disasters or significant illness.</p>
<p>Compulsive checkers repeatedly check power points, stoves and locks in an <a href="https://www.australianacademicpress.com.au/books/details/125/DIRT_Danger_Ideation_Reduction_Therapy_for_Obsessive_Compulsive_Checkers_A_Comprehensive_Guide_to_Treatment">attempt to prevent harm</a> or death. <a href="https://www.researchgate.net/publication/280142510_Menzies_R_G_Menzies_R_E_Iverach_L_2015_The_role_of_death_fears_in_Obsessive_Compulsive_Disorder_Australian_Clinical_Psychologist_1_6-11">Compulsive hand washers often fear</a> contracting chronic and life-threatening diseases.</p>
<p>People with panic disorder frequently visit the doctor <a href="http://www.jpsychores.com/article/S0022-3999(97)00135-9/abstract">because they’re afraid</a> of dying from a heart attack. Meanwhile, those with somatic symptom disorders, including those formerly identified as hypochondriacs, frequently request medical tests and body scans to identify serious illness. </p>
<p>Finally, specific phobias are characterised by excessive fears of heights, spiders, snakes and blood – all of which are associated with death. Phobic responses to seeing a spider, for instance, typically involve jumping, screaming and shaking. Some <a href="http://psp.sagepub.com/content/early/2007/06/01/0146167207303018.short">researchers argue</a> these extreme responses could actually represent rational reactions to more significant threats, such as seeing a person with a weapon.</p>
<h2>Priming death</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Compulsive hand washers used more paper towels when primed with death.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>More evidence for the TMT hypothesis comes from studies showing that death anxiety is capable of increasing anxious and phobic responding.</p>
<p>These studies use a popular “<a href="http://psr.sagepub.com/content/14/2/155.abstract">mortality salience induction</a>” technique to prime death anxiety in people with other anxiety disorders. The technique involves <a href="http://psr.sagepub.com/content/14/2/155.abstract">participants writing down</a> the emotions that the thought of their own death arouses, as well as detailing what they think will happen as they die and once they are dead. </p>
<p>Spider phobics primed like this had <a href="https://arizona.pure.elsevier.com/en/publications/terror-mismanagement-evidence-that-mortality-salience-exacerbates">increased reactions</a> to spiders, such as avoiding looking at spider-related images, when compared to spider phobics not primed with death. And compulsive hand washers spent more time washing their hands and used more paper towels when primed with death.</p>
<p>Likewise, <a href="http://www.tandfonline.com/doi/full/10.1080/02699931.2015.1065794#.VyFiVEIqv8s">those with social phobias took longer</a> to join social interactions. After they had been reminded of death, they also viewed happy and angry faces as more socially threatening – as <a href="http://www.ncbi.nlm.nih.gov/pubmed/17884328">these faces indicate judgement</a> – than neutral, seemingly innocuous faces. </p>
<h2>Is fear of death normal?</h2>
<p>Given that we are all going to die at some point, death anxiety is a normal part of the human experience. For many of us, thinking about death can evoke fears of separation, loss, pain, suffering and anxiety about leaving those we love behind. </p>
<p>According to terror management theory, this fear has the power to motivate a life well lived. It stimulates us to cherish those we love, create enduring memories, pursue our hopes and dreams and achieve our potential. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?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">Death anxiety is a normal part of human experience.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/bSYRuzEaT5k">Neil Thomas/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Death anxiety becomes abnormal when it forms the basis of pathological thoughts and behaviours that interfere with normal living. Many obsessive-compulsive hand washers and checkers <a href="http://www.researchonline.mq.edu.au/vital/access/manager/Repository/mq:42972">spend significant amounts of time</a> each day in ritualistic behaviours designed to reduce the threat of dirt, germs, fire, home invasion or threats to themselves and loved ones. </p>
<p>Similarly, those with phobias may go to extreme lengths to avoid what they fear and react with extreme distress when confronted with it. When these thoughts and behaviours lead to impaired functioning, anxiety is no longer considered “normal”.</p>
<p>Treatments, such as cognitive behaviour therapy, for a range of disorders may need to incorporate new strategies that directly address death anxiety. Without such innovation, the spectre of death may tragically haunt the anxious across their lifespan, until it is too late.</p><img src="https://counter.theconversation.com/content/57057/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>We manage our fear of death by creating a sense of permanence and meaning in life. But for some people, death anxiety results in pathological coping mechanisms, such as being afraid of spiders.Lisa Iverach, Honorary Associate at Department of Psychology, Macquarie University and Research Fellow, University of SydneyRachel E. Menzies, PhD candidate, Clinical Psychology, University of SydneyRoss Menzies, Associate Professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/504102015-11-26T04:32:44Z2015-11-26T04:32:44ZSouth Africa isn’t managing mental illness, particularly for the poor<figure><img src="https://images.theconversation.com/files/103174/original/image-20151125-23833-afwxoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A child from a special care centre in Cape Town celebrating international kite day. In South Africa mental health services are not a priority. </span> <span class="attribution"><span class="source">Epa/Nic Bothma </span></span></figcaption></figure><p>Mental health conditions, disorders and diseases are rarely on the frontline of health regulations and international health agendas. But global institutions such as the World Health <a href="http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf">Organisation</a> have been engaging with governments to improve mental health systems.</p>
<p><a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001178">Research</a> shows there are several barriers blocking improving mental health care. These include diminished civil society support, a lack of global consensus on mental illness and its treatment, missed policy opportunities and limited evidence on the delivery of mental health interventions.</p>
<p>But in the last two decades increased attention has been given to mental health as a global priority. Civil society has become more active. In addition, high impact journals such as <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000160">PLoS Medicine</a> and <a href="http://www.thelancet.com/series/global-mental-health-2011">The Lancet</a> have raised the profile of mental health. </p>
<p>The new sustainable development goals have also put mental health and wellbeing firmly on the agenda, although there has been <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001846">criticism</a> that the goals fall short of their true potential. </p>
<p>It is estimated that globally between 12% and 48% of people suffer from mental <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001178">disorders</a>. Over 70% of this burden lies in low and middle income countries. </p>
<p>In South Africa, as in many developing countries, mental health doesn’t feature as a public health <a href="http://www.dailymaverick.co.za/article/2015-07-15-psychiatry-in-distress-how-far-has-south-africa-progressed-in-supporting-mental-health/#.VlWQR3YrLIU">priority</a>. In <a href="http://www.who.int/mental_health/evidence/south_africa_who_aims_report.pdf">rural</a> communities mental health is not supported at all. </p>
<p>One of the consequences is that trauma is common in South African society. This is evident from unusually high interpersonal <a href="https://africacheck.org/2014/09/17/comment-why-is-crime-and-violence-so-high-in-south-africa-2/">violence</a>, including homicide, rape and domestic violence.</p>
<h2>Low levels of care</h2>
<p>At least 15% of those interviewed for the South African Stress and Health <a href="http://www.ncbi.nlm.nih.gov/pubmed/18245026">Study</a> - the first nationally representative survey of psychiatric disorders in an African country - said they suffered from anxiety disorders. These could include obsessive compulsive disorder, post traumatic stress disorders and panic disorders. Nearly 10% suffered from mood disorders such as depression or bipolar disorders. Another 9% suffer from substance abuse disorders. Nearly a third of the respondents reported a lifetime history of at least one psychiatric disorder. </p>
<p>But only about a quarter of those who needed treatment were getting access. This is partly because expenditure on mental health is <a href="http://www.who.int/mental_health/evidence/south_africa_who_aims_report.pdf">pitiful</a>. On average, provinces spend less than 3% of their health budgets on mental health, mostly on psychiatric hospitals which, in any case, should be the last resort in the chain of treatment. </p>
<p>There are several other reasons for this dismal provision. These include:</p>
<ul>
<li><p><a href="http://www.who.int/mental_health/policy/services/integratingmhintoprimarycare/en/">vast distances</a> to access specialized services,</p></li>
<li><p>the chronic <a href="http://www.ncbi.nlm.nih.gov/pubmed/2499642">stigma</a> barrier in public health facilities, </p></li>
<li><p>inequality and poverty. People suffering from mental illness are caught in a “cycle of <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2960754-X/abstract">poverty</a>”, which leaves little prospect of escape.</p></li>
</ul>
<h2>Where are the carers</h2>
<p>South Africa’s mental health <a href="http://www.ncbi.nlm.nih.gov/pubmed/19506789">workforce</a> is woefully inadequate. There are only 0.3 psychiatrists, 0.3 psychologists and 0.4 social workers for every 100 000 residents. <a href="http://www.who.int/mental_health/evidence/atlas/profiles/bra_mh_profile.pdf">Brazil</a> has 3.07 psychiatrists, 9.60 psychologists and 1.02 social workers for every 100 000 residents.</p>
<p>South Africa has 800 registered psychiatrists and nearly 8 000 psychologists, mostly working in private <a href="http://www.health-e.org.za/2015/10/12/mental-health-the-poor-neglected-stepchild/">health</a>.</p>
<p>Although the government has made significant strides creating <a href="http://www.health-e.org.za/wp-content/uploads/2014/10/National-Mental-Health-Policy-Framework-and-Strategic-Plan-2013-2020.pdf">policy</a> and passing <a href="http://www.gov.za/sites/www.gov.za/files/38182_rg10309_gon874_0.pdf">legislation</a> to provide mental health services, implementation has been a problem. This is because:</p>
<ul>
<li><p>Most of the groups supporting people with mental disorders are non-profit organisations that survive on shoestring budgets. </p></li>
<li><p>A shortage of state resources for the specialised and complex needs of psychiatric disorders.</p></li>
</ul>
<p>There should be strong collaboration between the service providers, particularly non-profit organisations, and the private sector. This does not happen. </p>
<p>Recent developments are not promising. The Gauteng Department of Health <a href="http://www.gov.za/speeches/gauteng-health-terminates-life-healthcare-esidimeni-contract-21-oct-2015-0000">announced</a> it will end its contractual relationship with Life Healthcare – South Africa’s largest and longest running public-private partnership. This will result in more than 2000 patients with chronic mental illness being discharged from Life Esidimeni, which means “place of dignity”. </p>
<p>In the absence of proper community care, people who need care often end up homeless or in jail as has been shown in the <a href="http://www.ncbi.nlm.nih.gov/pubmed/6479924">US</a>. In addition, pressure increases on under-funded non-profit organisations.</p>
<h2>Glimmers of hope</h2>
<p>There are some promising initiatives in the pipeline to strengthen mental healthcare in the country and in parts of the continent. </p>
<p>This includes groups that empower practitioners and policy makers enabling them to <a href="http://www.cpmh.org.za/">lobby</a> for mental health services. There are also consortia that investigate cost effective <a href="http://www.affirm.uct.ac.za/">interventions</a> for mental health disorders, how to <a href="http://www.prime.uct.ac.za/">scale up</a> mental health services and enhance the health systems to deliver mental health services adequately. </p>
<p>The state has a responsibility to provide mental illness treatment and to promote mental health. But the reality is that it will need to tap into human resources from non-profit organisations as well as private sector funding. This collaboration can only happen if the state renews its focus on how it can deliver mental health services.</p><img src="https://counter.theconversation.com/content/50410/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>André Janse van Rensburg is affiliated with the University of Stellenbosch (Department of Political science) and Ghent University (Department of Sociology) as a doctoral candidate, and with the Centre for Health Systems Research & Development, University of the Free State, as a researcher.</span></em></p>While the global health community has made mental healthcare a priority, South Africa is not following suite. The impact is felt most acutely by poor people suffering from mental health disorders.André Janse van Rensburg, Researcher at the Centre for Health Systems Research & Development, University of the Free StateLicensed 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>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/98688/original/image-20151016-25112-bpzxvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98688/original/image-20151016-25112-bpzxvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98688/original/image-20151016-25112-bpzxvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98688/original/image-20151016-25112-bpzxvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98688/original/image-20151016-25112-bpzxvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98688/original/image-20151016-25112-bpzxvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98688/original/image-20151016-25112-bpzxvy.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">Did I leave the gas on?</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<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.tag:theconversation.com,2011:article/428352015-06-15T04:04:54Z2015-06-15T04:04:54ZSeven new genes linked to anxiety disorders<figure><img src="https://images.theconversation.com/files/84407/original/image-20150609-10747-bcbx77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug-based therapies for anxiety disorders work on roughly half of those affected and treated.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Researchers have linked seven new genes to anxiety disorders such as obsessive compulsive disorder, panic disorder and social anxiety disorder. </p>
<p>These gene links mean that new drug treatments could be created to target these gene products specifically in the treatment of anxiety disorders. It gives hope to thousands of people who currently have no treatment plan. </p>
<p>Treatments for anxiety disorders involve both drug-free and <a href="http://www.nimh.nih.gov/health/publications/anxiety-disorders/index">drug-based therapies</a>. The most effective treatment strategies are a combination of the two, differing in application from patient to patient. </p>
<p>To treat these conditions using drug-based therapies, drugs have been designed to target specific genes which produce proteins associated with the progression of disorders. Because these disorders are so complex, gene discovery is difficult. </p>
<p>Currently, there are only two core pathways that are associated with drug-based therapies: the dopaminergic and the serotonergic pathways. Dopamine changes have been linked to movement, motivation, reward-response and addiction. Serotonin in the brain has been linked to mood, social behaviour, memory and cognitive function.</p>
<p>Drug-based therapies work on roughly half of those affected and treated, leaving a large number of people <a href="http://www.appi.org/Book/Subscription/JournalSubscription/id-1336/Clinical_Manual_of_Anxiety_Disorders">without tangible assistance</a>. The current treatments for anxiety disorders are not as effective as hoped. A better understanding of why and how these disorders exist is essential for better treatment strategies.</p>
<h2>Looking at novel gene targets</h2>
<p>Our <a href="https://www.researchgate.net/publication/265476243_THE_IDENTIFICATION_OF_NOVEL_SUSCEPTIBILITY_GENES_INVOLVED_IN_ANXIETY_DISORDERS">research</a> uncovered several new genes that could potentially play roles in how anxiety disorders develop and progress. We used an interdisciplinary approach on both animals and people to uncover these genes.</p>
<p>To help us identify the candidate genes, we focused on the striatum section of the brain in which the synaptic plasticity pathway was chosen. In neuroscience, synaptic plasticity refers to the ability of synapses (connections in the brain) to strengthen or weaken over time in response to a stimulus. The striatum helps co-ordinate motivation with body movement. It can be as simple as fine-motor function or as complex as behavioural inhibition depending on social interaction. </p>
<p>The result was that we identified seven new genes as <a href="https://www.researchgate.net/publication/265476243_THE_IDENTIFICATION_OF_NOVEL_SUSCEPTIBILITY_GENES_INVOLVED_IN_ANXIETY_DISORDERS">possible candidates for further study</a>. Six of these genes have never been implicated in anxiety disorders before. </p>
<p>To date, global research has identified a number of risk factors for anxiety disorders. These can be grouped into two categories: genetic factors and environmental factors. Genetic factors relate to differences in one’s genetic code that either protect or put you at risk for developing anxiety disorders. Environmental factors include childhood trauma and substance abuse.</p>
<p>To further complicate things, these categories tend to interact with one another.
Scientists believe the interaction is what results in a plethora of differences among patients even when they have the same disorder. For example, two people may have severe obsessive compulsive disorder and be on the same treatment schedule. Due to the differences in their genetic make-up and lifestyles, they could respond differently to treatment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/84409/original/image-20150609-10747-18vzvsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84409/original/image-20150609-10747-18vzvsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84409/original/image-20150609-10747-18vzvsi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84409/original/image-20150609-10747-18vzvsi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84409/original/image-20150609-10747-18vzvsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84409/original/image-20150609-10747-18vzvsi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84409/original/image-20150609-10747-18vzvsi.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">Drug-based therapies only work for half of the people suffering from anxiety disorders.</span>
<span class="attribution"><span class="source">shutterstock</span></span>
</figcaption>
</figure>
<p>Some of these candidates also appear to interact with environmental stressors. <a href="http://www.sciencedirect.com/science/article/pii/S002239561300263X">Trauma</a> experienced during early developmental years has been thought to be a risk factor for anxiety disorders for a number of years now. It is believed to be a key factor in the variation seen among different patients. </p>
<p>Although this theory is difficult to investigate and depict, it was possible using the strict and specific conditions that we did. The finding provides a precedent for future work to try and better understand how the environment interacts with genetics to manifest in disease.</p>
<p>Anxiety disorders such as obsessive compulsive disorder, panic disorder and social anxiety disorder are among the most severe and debilitating conditions. They currently affect up to [350 million people worldwide](http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13).</p>
<p>Despite this disease burden, they have not achieved the visibility, attention or funding they <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001178">comparatively deserve</a>. For example, the <a href="http://report.nih.gov/categorical_spending.aspx">US</a> allocated (in millions) $3920 to cover all brain disorders research for the 2015 financial year. HIV, with an incidence rate well below anxiety disorder – let alone brain disorders in general – received $3000 (in millions).</p>
<p>Myths, fear and stigma are the persistent barriers in the understanding of mental illness. It also hampers <a href="http://wfmh.com/wp-content/uploads/2013/11/WFMH_GIAS_UnderstandingGeneralizedAnxiety.pdf">public awareness</a>. As a result, as history has shown, those who suffer from mental health illnesses have been ostracised in communities, treated with prejudice and considered second-class citizens.</p>
<h2>The way forward</h2>
<p>By uncovering these new candidates genes – involved not only in risk, but environmental interplay – there is new hope for better and improved treatment strategies.</p>
<p>But whether it is by realising new drug targets, a better understanding at a molecular level or how one’s environment influences disease, a small – yet promising – arsenal of candidates could shed a little more light on a rather dimly lit road.</p><img src="https://counter.theconversation.com/content/42835/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nathaniel McGregor receives funding from the National Research Foundation (NRF). He is affiliated with the MRC Unit on Anxiety and Stress Disorders.</span></em></p>There is hope that new drugs can be created to treat anxiety disorders after seven new genes were linked to these diseases.Dr Nathaniel McGregor, Postsdoctoral Researcher, Department of Psychiatry and Department of Genetics, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/317132014-09-24T05:28:04Z2014-09-24T05:28:04ZHow neuroscience can teach children about mental health<figure><img src="https://images.theconversation.com/files/59805/original/gq669nc4-1411487702.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Brain on the whiteboard.</span> <span class="attribution"><span class="source">Brain by Shutterstock</span></span></figcaption></figure><p>At a recent talk I gave as a Sheffield NeuroGirl, a group of three female PhD students who aim to bring interesting and exciting research on the brain to the public, I carried out a little experiment. I asked everyone to get to their feet and then for everyone who either had, or knew someone with a mental illness to sit back down again. Amazingly, only two people were left standing. </p>
<p>This is by no means an unusual state of affairs. <a href="http://www.who.int/whr/2001/media_centre/press_release/en/">One in four</a> people will experience some kind of mental health problem, including 10% of all children. Suicide is the second leading cause of death among 15 to 29-year-olds across the globe, with depression <a href="https://theconversation.com/who-suicide-report-shows-we-must-stop-seeing-depression-as-a-disorder-of-developed-world-30846">a major risk factor</a>. And a breakdown in a healthy brain is indiscriminate in who it targets: rich, poor, all races and both sexes.</p>
<p>Yet negative attitudes from the stigma of mental health problems are still very prevalent, and the <a href="http://onlinelibrary.wiley.com/doi/10.1002/j.1556-6678.2008.tb00491.x/abstract">perception of those</a> that seek help for mental ill health is <a href="http://informahealthcare.com/doi/abs/10.1080/0963823031000118230">that they are</a> “crazy”, “weak”, “flawed” or “dangerous”.</p>
<p><a href="http://link.springer.com/article/10.1007%2Fs10964-006-9091-0#page-1">A 2007 study</a> found that anticipated negative attitudes – from peers, family members and even school staff – were crucial to whether they sought help for mental health problems. So why is there still so little education on the brain and how it works in schools? Lessons could teach children what our brains do and why they might go wrong. If mental health will likely touch us all at some point throughout our lives, can we not begin to understand it earlier? </p>
<p>If a child breaks their arm, everyone talks about it; from how it was broken, why it hurts, how it will mend, potential complications. No-one bats an eyelid about seeing a cast. However, if a child becomes depressed, there is usually no frank discussion about what might be wrong with their brain and why they could be feeling down. Although there are treatments available, there may be a big gap in explaining the processes happening in the brain. </p>
<p>Neuroscience, which investigates how the central nervous system and the brain functions in health and in disease, can inform education and reduce stigma. Those of us who study or work in neuroscience are aware of the many problems the brain can face throughout its lifetime. </p>
<p>We know for, example, that you can’t just “snap out” of deep depression, because many brain imaging studies have shown there are abnormalities in the way that the depressed brain works. <a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0032508">A study</a> by Andrew Leuchter and colleagues at UCLA used EEG to measure brain signals and found that the limbic region, an area involved in processing emotion, and cortical brain regions such as the dorsolateral prefrontal cortex, which is involved in the regulation of thinking and action, sent many more messages back and forth in participants suffering from major depressive disorder compared to those with healthy brains. </p>
<p>Neuroscience can also convey to a child the underlying issue beneath their problem. For example, the role of an area buried deep in the brain called the caudate putamen, which helps to control voluntary movement but is also believed to play a role in Obsessive Compulsive Disorder (OCD). In people with OCD, problems with the caudate putamen can mean an inability to stop worrying or stop having anxious thoughts. </p>
<p>Although environment and life circumstances play their part in depression, it is also a physical manifestation. And understanding this can help move a narrative from blaming the sufferer for being crazy, or weak, to acknowledging that part of the brain is no longer healthy. Just as you can become sick with a cold, your brain can also become sick. This is an important message that we could teach much more.</p>
<p>Ignorance about mental health can lead to bullying, prejudice, fear and heartache. It can lead to resistance in those suffering to seek the help and support for those around them, unnecessary fear and worry. For children especially, not understanding mental illness could potentially also lead to guilt that they have somehow caused it.</p>
<p>A simple programme of education in schools could help to bring about a real change in society. It could help to provide a long-term solution to the problem of ignorance about mental health and bring more discussion about mental illness into the open. While some of this work could be done by people going into schools, a better solution would be to add the brain itself into the national curriculum.</p><img src="https://counter.theconversation.com/content/31713/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Slack is one of the Sheffield NeuroGirls @Shef_NeuroGirls</span></em></p>At a recent talk I gave as a Sheffield NeuroGirl, a group of three female PhD students who aim to bring interesting and exciting research on the brain to the public, I carried out a little experiment…Rebecca Slack, PhD researcher in Neuroscience, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/267922014-05-19T14:00:00Z2014-05-19T14:00:00ZElectrical signature from OCD can be picked up in the brain<figure><img src="https://images.theconversation.com/files/48743/original/f5nbgw4d-1400254584.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reading thoughts.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/64958688@N00/5483528188/sizes/l">Scribbletaylor</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Obsessive-compulsive disorder (OCD) is an anxiety-related mental condition that affects 1-2% of the population. It is <a href="http://www.theguardian.com/tv-and-radio/2013/nov/01/bedlam-tv-review">severely debilitating</a> and can strike anyone regardless of age, gender and cultural background. The majority of us will be familiar with its overt symptoms, such as obsessive checking, compulsive washing or performing routines ritualistically, but less is known about how the disorder manifests in the thought processes behind the compulsions. </p>
<p>Our research, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871292/">recently published</a> in Neuroimage: Clinical, set out to discover what happens in the brain when people experience a spurious fusion between negative thoughts and actions. We found that the worse the condition was, the greater the amount of high frequency brain activity in the precuneus, a part of the cerebral cortex (the outer part of the brain). This is a key area because it has extensive connections to widespread brain regions and acts as a hub for the default network, a group of brain areas activated when we are internally focused with self-referential thoughts. </p>
<p>At some point in our life we all experience negative unwanted thoughts, like the thought or image of a loved one coming to harm. While the majority of us are capable of brushing away these thoughts without much trouble, an OCD sufferer can’t. They’re likely to misinterpret the thought as being important; a dangerous one that requires preventive action.</p>
<p>One variety of misinterpretation that OCD sufferers experience is Thought-Action Fusion, or TAF. It is the belief that thoughts and actions are inextricably linked, and that thoughts, mostly negative, can have real-world consequences. For example, an OCD sufferer who has a thought of her child becoming ill would feel that by merely having the thought, she has increased the likelihood of her child becoming ill in reality. This leads to an inflated sense of responsibility for harm, which causes a great deal of anxiety and guilt. </p>
<p>It also comes with the urge to do something to avert the catastrophe. Sufferers may then engage in compulsive behaviours or mental rituals to neutralise the imminent threat. While this behaviour will provide some relief, by reducing anxiety, the effect is short-lived. Eventually it only serves to reinforce the beliefs that the compulsions are working and that leads to a vicious circle of obsessions and compulsions.</p>
<p>Learning more about the biological basis of this underlying cognitive bias may help in the search for new treatments for people with OCD so we induced thought-action fusion in two groups of participants – one with high levels of obsessive-compulsive symptoms (high-OC) and another with low levels of symmptoms (low-OC) – and recorded the accompanying brain activity using electroencephalography (EEG), which measures electrical activity along the scalp.</p>
<p>We found that the high-OC group experienced a significantly greater magnitude of thought-action fusion than the low-OC group, and reported far higher levels of anxiety, guilt, and the urge to neutralise. When we looked at the accompanying brain activity we found that the greater magnitude was correlated with more high-frequency brain activity in the precuneus. </p>
<p>Now we have found what appears to be a neural signature for thought-action fusion, our next step is to explore ways to modify its activities which may help break the vicious circle in the OCD thinking process.</p><img src="https://counter.theconversation.com/content/26792/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>Obsessive-compulsive disorder (OCD) is an anxiety-related mental condition that affects 1-2% of the population. It is severely debilitating and can strike anyone regardless of age, gender and cultural…Joydeep Bhattacharya, Professor of Psychology, Goldsmiths, University of LondonRhiannon Jones, Lecturer in Psychology, University of WinchesterLicensed as Creative Commons – attribution, no derivatives.