The Importance of Treating OCD Earlier: The Washington Post Article on Ethan’s Struggle from Childhood OCD through Adulthood

In people who develop obsessive-compulsive disorder, there are often signs in childhood. However, OCD in children can be hard to distinguish from childhood fears and age-appropriate magical thinking. For OCD Awareness Week, The Washington Post published an article by Sarah Maraniss-Vander Schaaf about the experiences of Ethan, a young man who developed OCD in childhood. It’s an effort to help people look past the stereotypes of people with OCD as being excessively clean and organized or washing their hands excessively. As the writer notes:

“…true OCD is often unspoken. It’s hard to recognize, as well, when growing up in a family where anxiety is normal, or in a school where behavior might be labeled school avoidance, or when no one else talks about the secret rituals that are too private to mention.”

The article traces the development of Ethan’s OCD from early childhood, though college, and the following decade of adulthood. It documents how OCD obsessions and rituals can escalate when left untreated and unchecked, and it provides a sober illustration of how the accommodation by the loved ones of someone with OCD’s obsessions/rituals—however well-meaning—can have disastrous consequences over time.

I’ve written in other posts about how some people with OCD have difficulty accessing appropriate treatments. Ethan was eventually accurately diagnosed and offered effective treatment, but it took several attempts before he was fully willing and able to engage treatment. He was even kicked out of OCD Institute at McLean Hospital, one of the leading residential treatment programs for people with OCD. Ethan didn’t recover from OCD until he was willing to commit to proper treatment—particularly exposure and response prevention. Ms. Maraniss-Vander Schaaf writes:

His improvement came when he accepted CBT and Exposure Response Prevention (ERP). He was taught to develop a new relationship with his thoughts. He learned to live with the uncertainties of life and not push away anxiety with obsessive-compulsive thoughts and actions.

Ethan’s story is inspiring as, even after 2 decades of struggling with severe OCD, he is currently enjoying a productive and independent life. As I work with adults, I don’t often have a full view of how OCD progresses across the lifespan in the clients I see. I found this article of Ethan’s personal journey into OCD illuminating in how it presents a narrative of someone’s struggles with OCD across more than 2 decades, and the way OCD symptoms can change, transform, and evolve over time.

You can read the full article here.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website.

If you want to learn about OCD, here’s post about a great introductory book, Tompkins’ OCD: A Guide for the Newly Diagnosed.

The Difficulties of Accessing Effective Treatment: OCD as an Example

I resonated with a recent article in Psychology Today about the difficulties people have in finding therapists who offer effective treatment. The authors Dean McKay and Scott Lilienfeld—especially Dr. Lilienfeld—have been extremely active in promoting science-based psychotherapies.

As an example, they offer the experience of “Jerry” (a pseudonym). Jerry struggled with obsessive-compulsive disorder (OCD). Having educated himself on OCD, Jerry knew that exposure and response (or ritual) prevention (ERP, for short) was the most researched and effective treatment for OCD. ERP involve systematically helping people with OCD learn to confront obsessions while resisting the urge to engage in compulsions or rituals.

Despite living in a major city, it took Jerry 3 years to find a therapist who offered and was proficient in ERP for OCD. Jerry’s experiences are similar to those of a Yale graduate student with OCD.

Many clients I’ve seen have similarly struggled. Some were misdiagnosed by prior therapists and did not even realize they had OCD until they did their own research. Some therapists correctly identified them as having OCD but when it came to treatment, they “just talked.”

Most people with OCD with whom I’ve worked have seen at least 1 or 2 therapists who have not been particularly helpful. Hair pulling (trichotillomania) and skin picking (excoriation) are two other problems that people with whom I’ve worked have struggled to find effective treatment.

The article by Drs. McKay and Lilienfeld provides a sober reminder that there are a number of people who would benefit from effective treatments such as ERP but cannot find therapists who practice it or are aware enough of their competency to refer out to a specialist. Unlike Jerry, many people with problems such as OCD, trichotillomania, and excoriation don’t even realize there’s a name for their struggles, let alone effective treatment, and they may drift in and out of therapists’ offices being misdiagnosed and receiving substandard treatment.

Drs. McKay and Lilienfeld recommend that:

The adoption of the new clinical practice guidelines is probably our field’s best hope for placing long overdue pressure on therapists to incorporate scientifically based approaches into their clinical practices. Practice guidelines would also assist mental health consumers with the daunting task of selecting more effective treatments.   

 

Sadly, there are many licensed therapists who do not believe in science-based approaches. For people with mild to moderate depression/anxiety, generic talk therapy and nonscientific approaches can offer some relief. For people like Jerry with OCD, these unscientific approaches are unlikely to be of much help.

I’m inspired that psychologists such as Drs. McKay and Lilienfeld take time from their busy schedules as full-time professors and respected researchers to promote scientific approaches. You can read their blog post here. I encourage readers to carefully research the therapists you or your loved ones see, and not to stay in therapy with someone who doesn’t seem to be very helpful.

Hair Pulling (AKA Trichotillomania) and Skin Picking Problems – Greater Research Support for Behavior Therapy over Medication

Trichotillomania (or trich for short) is a condition in which people repeatedly pull out their body hair, often leading to bald patches and thinning. The scalp is a common site—as are eyebrows and eyelashes—but some may pick at hair anywhere on the body. A related condition is repetitive skin picking. This condition did not have an official diagnostic name until 2013, when the most recent edition of the DSM psychiatric guide decided on the name excoriation. People with an excoriation disorder pick or scratch at their skin—often at perceived imperfections or blemishes—to the degree that they may cause marks, bleeding, and scarring.

Both are broadly categorized as body-focused repetitive behaviors, and these have recently been more broadly categorized and obsessive-compulsive and related disorders. People with these problems often experience a great deal of shame and embarrassment about their difficulties and have an extremely tough time stopping.

Unfortunately, both conditions are understudied and not well-known. Many people struggle with them without realizing there is even a name for their condition.

The treatment literature is relatively small compared to problems such as depression and anxiety. However, I recently came across a nice summary of treatment options for trichotillomania and skin picking, as well as other conditions more broadly called obsessive-compulsive and related disorders.

Cognitive Behavioral Therapy

For hair pulling, cognitive behavioral therapy has the greatest research support. An intervention called habit reversal training has been the most studied, either by itself or in combination with a more comprehensive cognitive behavioral treatment such as Acceptance and Commitment Therapy (called “act” for short).

With excoriation, there is evidence that treatments that work for hair pulling also work for skin picking. Unfortunately, the treatment evidence for excoriation is more limited. Although it was studied for decades before being given an official diagnosis in 2013, I suspect not having an official diagnosis slowed research interest. Hopefully, we will begin to see more research on skin picking.

Medication

Rigorous research on the use of medication is much less robust than the research on therapy. There’s some evidence that the antidepressant clomipramine may help reduce hair pulling, but controlled studies on the use of SSRI’s—the most common class of antidepressants—have not shown much effectiveness. Of the SSRI’s, fluoxetine has been the most studied, but it’s effectiveness with hair pulling has been very mixed.

There’s some research support for the use of antidepressants in reducing skin picking; however, there have been no large controlled trials.

My Impressions

The research matches my experience as a therapist. Many people I’ve treated for hair pulling or skin picking have tried medication first and have either not found it helpful at all or have been unclear about whether it was effective or not. If someone’s anxiety is contributing to pulling or picking behavior, medication may help reduce the tendency somewhat but is not likely to be a total cure.

I should also acknowledge that behavioral treatment for picking and pulling is hard work. It takes a lot of attention and effort to change these habits, and many people who do well with treatment continue to struggle with it to some degree. For these reasons, it is important to see a specialist in hair pulling and skin picking. Generic talk therapy is unlikely to be of much help.

Summary

In sum, some form of cognitive behavioral treatment—especially with habit reversal training—with an experienced specialist should be the first-line treatment for hair pulling and skin picking.

As I’ve written about before, the Trichotillomania Learning Center is a great grassroots resource for learning more about hair pulling and skin picking.

If you’d like to read the full article yourself, you can download it here.

Follow up on the Valkee device that shines light in your ears.

This post is a follow up to something one of our researchers wrote two years ago about a device called the “Valkee” that shines light into your ears using a device that looks a lot like an iPod. The device supposedly cures seasonal affective disorder and is now being marketed in the USA. I felt the need to post an update to alert consumers to this device that uses slick marketing, but which does not appear to have produced any direct evidence to show that is more than a placebo in the treatment of seasonal affective disorder.  Here’s what we said about it two years ago:

It’s not available in the U.S. yet, but a Finnish company is marketing a new device called “Valkee.” It looks like an iPod, except instead of digital music, the headphones shine light into your ear. Yes, that’s right, the Valkee has small ear buds that shine light into your ear.

Why would shining bright light in your ear help with seasonal depression? Here’s where things turn a little fuzzy.

In the two years since we originally posted about this device and in the seven years since it was first created, the company has yet to generate any data showing that the device works better than a placebo for seasonal affective disorder. Placebo controlled trials are not that hard to do and the lack of such research is very concerning. Placebo effects can be quite strong and because of this effect, it can sometimes be hard to know whether a device works because it actually works, or just because people think it will work. In the case of the Valkee, the existing evidence points to the idea that the device works only because people expect it to work.

Thus, my recommendation is, if you are suffering from seasonal affective disorder, save the money you would have spent on the Valkee and use it instead to buy a more affordable and much more proven light therapy device. We review some of them here. If you want to read more about the controversy around this device, you can read more herehere, and here.

BTW, whenever I see a device or treatment that I’ve never heard of before, I always Google the name of that treatment and the word “scam” in Google. This applies whenever I see something new, in the service of being an informed consumer. If you google the item plus the word scam, you may find a range of relevant articles that can help you better evaluate whatever it is. Don’t believe us about the Valkee, do your own research before you make a purchase. Google “Valkee scam” and read what comes up.

Update 11/4/14: A Valkee-related team appears to have published their first trial designed to compare the Valkee to a placebo for seasonal affective disorder. The results showed that the Valkee was no better than what was identified as the placebo condition during trial registration. See the published study here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207317/ and here: http://clinicaltrials.gov/ct2/show/NCT01293409)?

I also found a new page where different people are discussing the Valkee device, in case you want to read more: http://tech.eu/features/215/valkee-conundrum-ive-shining-bright-light-brain-weeks-now-dont-know/

What Exactly is Insomnia? (and what you can do about it)

People can experience many difficulties with sleep throughout their lives.  Some people are often told by their parents that even as small children they were never “good sleepers.” Some people experience issues with sleep following a stressful or traumatic event in their life.  Sometimes issues with sleep just seem to come out of nowhere. 

However people with insomnia all have the same thing in common – they are not sleeping well and things don’t seem to be getting any better anytime quick.

There are three main types of insomnia

  1. Difficulty falling asleep
  2. Difficulty staying asleep
  3. Waking up too early

The criteria for an official diagnosis of insomnia are as follows:

  1. Difficulty getting to sleep, difficulty staying sleep, or waking up too early.  Also if sleep is chronically non-restorative or poor in quality.
  2. These problems with sleep happen even when all the right circumstances are present (i.e. a dark, quiet room & no need to be anywhere for a period of time).
  3. The issues with sleep cause problems for the person during the day, including at least one of the following:
  • Fatigue
  • Problems with attention, concentration or memory
  • Social problems / work-related problems / poor school performance
  • Mood disturbance or irritability
  • Daytime sleepiness
  • Reduced motivation, energy, or initiative
  • Proneness for errors
  • Accidents at work or while driving
  • Tension, headaches, or gastrointestinal symptoms in response to sleep loss
  • Concerns or worries about sleep

American Academy of Sleep Medicine. (2005). The International Classification of Sleep Disorders (2nd Edition)

What is NOT Insomnia

It’s important to also know what sleep issues are not considered insomnia.  Here is a list of other common sleep disorders:

Narcolepsy is a neurological disorder caused by the brain’s inability to regulate sleep-wake cycles normally, which causes an abnormal daytime sleep pattern and also sudden muscular weakness often brought on by strong emotions.

Sleep Terrors are characterized by a sudden arousal from sleep along with intense fear.

Sleep Walking is when people engage in activities that are normally associated with wakefulness (such as walking, eating, or dressing) while unconscious of their behaviors.

Sleep Disordered Breathing is a category of problems such as sleep apnea or snoring.

Restless Legs Syndrome is experienced as an irresistible urge to move one’s body to stop uncomfortable or odd sensations.

Circadian Rhythm Disorders are types of sleep disorders that affect the timing of sleep (often caused by shift work or jet lag). For example, a person’s body may not want to go to sleep until 5am, even though they need to get to sleep around 11pm.

REM Sleep Behavior Disorder is a sleep disorder that involves acting out violent or dramatic dreams during sleep. 

Hypersomnia is a disorder characterized primarily by severe excessive daytime sleepiness which is not better explained by a medical illness or other sleep issue.

Good News for Insomnia Sufferers

If you believe you suffer from insomnia and not one of the other, related disorders then there is good news for you – there is an effective, natural treatment available.  The science of sleep medicine has developed many tools over time.  One of these tools is a medication-free approach to treating insomnia called Cognitive Behavioral Therapy for Insomnia (CBTI).

If you would are interested in learning more about how CBTI can help you can read more here or contact me using the form below for a FREE telephone consult.