A lesson learned from Hurricane Sandy

Hurricane Sandy did a lot of damage in my area (Long Island).  A lot of damage. Indeed, my office was closed for about two weeks.  I couldn’t call my patients and they couldn’t reach me.  Next time, I’ll make sure I have a better backup plan, although even cell phones weren’t working for the first few days as the cell towers also got damaged.

But all my young patients have returned to therapy, and it’s been interesting to hear how they and their families managed to cope with being without power and having their lives disrupted.

Now you might think that kids with a lot of OCD or anxiety problems would get even more anxious under unplanned and unpredictable circumstances, right?  Well, you’d be wrong.  As I saw after 9/11, kids with anxiety disorders actually did really well – as well as their non-anxious peers, anyway.  Most of the adults in my practice also reported no exacerbations in anxiety during the long power outage, although they reported more frustration and anger, as one might expect, since the adults were dealing with the power company and the children weren’t.

One of the things we also learned was that being without internet and electronics turned out to be a Very Good Thing.  Kids and teens in my practice reported that at first, they felt somewhat disconcerted or at a loss without their usual activities and online interactions, but after a while, they realized they were actually less stressed and more relaxed without all the internet and electronics.  Some found other ways to amuse themselves, like reading or going out more to play on the street during daylight hours when they might otherwise have been indoors on the computer.

Of course, having no school may well have contributed to their less anxious state, but it’s interesting that they uniformly reported feeling better without so much internet and electronics.

Now the trick is for us to capitalize on that awareness.

Carousel image credit: NOAA

NYC research study on OCD seeking participants

Occasionally I post research recruitment notices for studies that have received approval from their institutions and have provided me with a copy of their approval notice and recruitment request. Here’s one from Mount Sinai Medical Center in NYC:

Do you have Obsessive-Compulsive Disorder (OCD)?

If so, you might be eligible for a research study looking at cognition at The Mount Sinai Medical Center. You must be between the ages of 18 and 50 and in good physical health. We will ask you to come in for 2-3 separate appointments for a total time commitment of approximately 2 to 6 hours. You will be reimbursed for your participation at the rate of $25.00 per hour. You will receive no direct benefit for your participation in this study.

During this experiment you will be asked to complete some computer tasks. You may be asked to do this while sitting in an office, or while having your brain activity measured using functional magnetic resonance imaging (fMRI). We may also ask to record some physiological changes in your body while you complete the task.

For more information, call the Mount Sinai Psychiatric Neuroscience and Cognition Laboratory at (212) 241-2857 or email us at SinaiBrainLab@mssm.edu.  Please do not disclose any personal or sensitive information via email.

Please do not ask me any questions about the study as I know nothing about it. I’m merely giving them space to try to recruit participants as part of my commitment to supporting research.

Possible causes of sudden onset OCD in kids broadened

Criteria for a broadened syndrome of acute onset obsessive compulsive disorder (OCD) have been proposed by a National Institutes of Health scientist and her colleagues. The syndrome, Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), includes children and teens that suddenly develop on-again/off-again OCD symptoms or abnormal eating behaviors, along with other psychiatric symptoms – without any known cause.

PANS expands on Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS), which is limited to a subset of cases traceable to an autoimmune process triggered by a strep infection. A clinical trial testing an immune-based treatment for PANDAS is currently underway at NIH and Yale University (see below).

“Parents will describe children with PANS as overcome by a ‘ferocious’ onset of obsessive thoughts, compulsive rituals and overwhelming fears,” said Susan Swedo, M.D., of the NIH’s National Institute of Mental Health (NIMH), who first characterized PANDAS two decades ago. “Clinicians should consider PANS when children or adolescents present with such acute-onset of OCD or eating restrictions in the absence of a clear link to strep.”

Swedo, James Leckman, M.D., of Yale University, and Noel Rose, M.D., Ph.D. of Johns Hopkins University, propose working criteria for PANS in February 2012 in the open source journal Pediatrics & Therapeutics.

“As the field moves toward agreement on this broadened syndrome, affected youth will be more likely to receive appropriate care, regardless of whether they are seen by a neurologist, pediatrician or child psychiatrist,” said NIMH Director Thomas R. Insel, M.D.

Differing causes sharing a “common presentation”

The PANS criteria grew out of a PANDAS workshop convened at NIH in July 2010, by the NIMH Pediatric and Developmental Neuroscience Branch, which Swedo heads. It brought together a broad range of researchers, clinicians and advocates. The participants considered all cases of acute-onset OCD, regardless of potential cause.

Clinicians reported that evaluations of more than 400 youth diagnosed with PANDAS confirmed that affected boys outnumbered girls 2:1, with psychiatric symptoms, always including OCD, usually beginning before 8 years.

Although debate continues about the fine points, the field is now of one mind on the core concept of “acute and dramatic” onset of a constellation of psychiatric symptoms. There is also broad agreement on the need for a “centralized registry” that will enable the research community to analyze evidence from studies that will eventually pinpoint causes and treatments. Such a registry is currently under development by members of the International Obsessive Compulsive Foundation (IOCDF).

Since a diagnosis of PANS implies no specific cause, clinicians will have to evaluate and treat each affected youth on a case-by-case basis.

“PANS will likely turn out to include a number of related disorders with different causes that share a common presentation,” explained Swedo.

The authors propose that a patient must meet 3 diagnostic criteria for a diagnosis of PANS:

1. Abrupt, dramatic onset of OCD or anorexia.
2. Concurrent presence of at least two additional neuropsychiatric symptoms with similarly severe and acute onset. These include: anxiety; mood swings and depression; aggression, irritability and oppositional behaviors; developmental regression; sudden deterioration in school performance or learning abilities; sensory and motor abnormalities; somatic signs and symptoms.
3. Symptoms are unexplainable by a known neurologic or medical disorder.

Among the wide range of accompanying symptoms, children may appear terror stricken or suffer extreme separation anxiety, shift from laughter to tears for no apparent reason, or regress to temper tantrums, “baby talk” or bedwetting. In some cases, their handwriting and other fine motor skills worsen dramatically. Leckman’s team at the Yale Child Study Center is in the process of developing assessment tools for diagnosing the syndrome.

PANDAS treatment study targets errant antibodies

Meanwhile, Swedo, Leckman, and Madeleine Cunningham of the University of Oklahoma, and colleagues, are collaborating on a new, multi-site placebo-controlled study, testing the effectiveness of intravenous immunoglobulin (IVIG) for reducing OCD symptoms in children with PANDAS.

Previous human and animal research suggested mechanisms by which strep-triggered antibodies mistakenly attack specific brain circuitry, resulting in obsessional thoughts and compulsive behaviors.

“Strep bacteria has evolved a kind of camouflage to evade detection by the immune system,” Swedo explained. “It does this by displaying molecules on its cell wall that look nearly identical to molecules found in different tissues of the body, including the brain. Eventually, the immune system gets wise to this ‘molecular mimicry,’ recognizes strep as foreign, and produces antibodies against it; but because of the similarities, the antibodies sometimes react not only with the strep, but also with the mimicked molecules in the human host. Such cross-reactive ‘anti-brain’ antibodies can cause OCD, tics, and the other neuropsychiatric symptoms of PANDAS.”

IVIG, a medication derived from normal antibodies, neutralizes such harmful antibodies, restoring normal immune function. It is used to treat other autoimmune illnesses and showed promise in a pilot study with PANDAS patients.

“We predict that IVIG will have striking benefits for OCD and other psychiatric symptoms, and will prove most effective for children who show high levels of anti-brain antibodies when they enter the study,” said Swedo.

Prospective study participants are first screened by phone by investigators at the NIH or the Yale Child Study Center. Those who meet eligibility requirements are then randomized to receive either active IVIG or a placebo procedure during a brief inpatient stay at the NIH Clinical Center. The researchers remain blind to which children received the active medication; after 6 weeks of placebo control, they give any children whose symptoms fail to improve the option to receive open-label active treatment.

In addition to assaying for antibodies that attack brain cells, the researchers use magnetic resonance imaging to see if the treatment reduces inflammation in an area of the brain known as the basal ganglia, which is thought to be the target of the errant antibodies. They also analyze levels of immune system chemical messengers (cytokines) in cerebrospinal fluid and blood – with an eye to identifying biomarkers of disease activity and potential predictors of treatment response.

The study was launched with support from the NIH Clinical Center’s Bench to Bedside program, which encourages such intramural-extramural collaborations in translational science.

Reference:

Swedo, SE, Leckman JF, Rose, NR. From Research Subgroup to Clinical Syndrome: Modifying the PANDAS criteria to describe PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). Feb 2012, Pediatrics & Therapeutics.

Source:  National Institute of Mental Health

Climate Change Obsessions?

Sarah Harvey reports that doctors in New Zealand have observed that some patients with OCD are getting developing obsessions and compulsions relating to climate change:

More than a quarter of patients with obsessive compulsive disorder (OCD) in a recent study in Australia were found to have obsessions which directly related to climate change. The majority were male.

The patients were found to be carrying out rituals, such as checking lights, stoves and taps were turned off, so they could reduce their global footprint.

[...]

Two participants were convinced increased air temperatures would result in rapid evaporation of the water leading to their pets dying of thirst if they didn’t check that the water bowls were full.

Another patient was continually checking skirting boards, pipes, roofs and wooden structures for problems they were convinced were caused by global warming.

Study authors Mairwen Jones, Bethany Wootton, Lisa Vaccaro and Ross Menzies said: “While these behaviours are not particularly unusual for people with this condition, it was the rationale they provided for carrying them out that was surprising.

“Instead of checking and rechecking so as to prevent fire or flood, the rituals were specifically performed so as to reduce their global footprint, or respond to climate change-induced negative events.

“While it is not particularly surprising that some people with OCD may have concerns related to climate change, what is surprising is the extent of these concerns.”

Read more on Stuff.

I wonder how much and what kind of media coverage climate change issues got in New Zealand.  And whether these same individuals also have shown a tendency to develop obsessions or compulsions about other “scares” covered by the media.

Have any of my readers outside of New Zealand encountered this type of obsessive-compulsive behavior? If so, please use the Comments section to let me know.

Carousel image credit: NASA

The Benefits of Exercise on OCD Symptoms

Noted in The Yeshiva World:

In a review of three separate meta-analyses, investigators at Arizona State University found that patients who participated in at least 21 minutes daily of aerobic exercise experienced a reduction in anxiety (Petruzzello SJ et al; 1991). A more recent study from Canadian researchers at the University of Manitoba in Winnipeg noted that regular exercise may help people who suffer from OCD, phobias and other psychiatric disorders. When the investigators examined studies of anxiety disorder and exercise dating back to 1981, they found that strength training, running, walking, and other forms of aerobic exercise help relieve mild to moderate depression and may also help treat anxiety and substance abuse.

I’m looking forward to seeing how my daughter’s dissertation study comes out. And if you have a child who has, or may have, Post-Traumatic Stress Disorder, you may want to consider enrolling them in a similar study on the benefits of exercise.

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