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By Brian L. Odlaug, Samuel R. Chamberlain, and Jon E. Grant

Surprisingly, many of the common mental health conditions in the world also happen to be the least well known. While Obsessive Compulsive Disorder garners attention from international media, with celebrities talking openly about their experiences with the condition, Obsessive Compulsive Related Disorders are far less recognized and receive scant attention.

Obsessive Compulsive Related Disorders include body dysmorphic disorder, tic disorders (including Tourette’s Syndrome), hair pulling disorder, excoriation (skin picking) disorder, hoarding disorder, and hypochondriasis. The clinical course and severity of these disorders varies from person to person yet can often be recognized by common symptoms. One might ask, what makes these “disorders” in need of treatment rather than everyday habits? A “bad habit” becomes a diagnosable disorder when the behavior becomes hard to control, and has a negative impact on an individual’s ability to function: at home, at work, or in the community. These often impairing conditions affect millions of people around the world, but are usually hidden. What can we do to help those suffering in silence?

Promoting screening for Obsessive Compulsive and Related Disorders is of the utmost importance. Society, the media, and healthcare professionals also need to work together to increase awareness of these conditions and provide timely and adequate treatment. The majority of people with these conditions have never sought treatment, and may not even be aware that they have a medically recognized condition that is potentially treatable. Left untreated, Obsessive Compulsive and Related Disorders frequently follow a chronic course, meaning that symptoms often do not improve with time, without intervention. In fact, many people have suffered with the condition for 10, 20, even 30 or more years without clinical recognition. Few other classes of disorders — mental health or otherwise — carry the overall lack of recognition and treatment as these disorders.

Individuals living with these conditions also should be aware of valuable advocacy and support groups that exist worldwide, including the Trichotillomania Learning Center and Tourette’s Syndrome Association in the United States, and OCD Action in the United Kingdom, to name a few.

Bringing these disorders out from the shadows and into the mainstream of mental health and community consciousness can only serve to improve the quality of life for our family members, neighbors and friends.

Five things that you can do to help people who suffer from OCD:

1. Clinicians should screen for Trichotillomania and Excoriation Disorder in all patients, but especially women. Most people will not acknowledge the behavior readily and may not even know that they have a diagnosable and treatable problem.
2. Clinicians should be aware that although anxiety may worsen some of these behaviors, that OCD and the Related Disorders are not simply versions of anxiety and therefore must be treated differently.
3. Due to the potential impairment of OCD, clinicians need to take it seriously and not view it simply as an oddity.
4. Family members should be supportive of someone with OCD and not shame or embarrass the person into stopping the behavior.
5. People with these conditions can help themselves and others as well. Print out articles or information on your condition and show them to family, friends, or even your doctor. They might not know a lot about these disorders either and you can help educate them.

Brian L. Odlaug is a Visiting Researcher at the University of Copenhagen, Department of Public Health. Brian has authored or co-authored over 120 peer-reviewed articles and book chapters, specializing in the areas of addiction, impulse control and obsessive compulsive disorder. Samuel R. Chamberlain is a practicing psychiatrist and Clinical Lecturer at the Department of Psychiatry, University of Cambridge. He has published more than 100 peer-reviewed articles including first-authored papers in Science, the American Journal of Psychiatry, the British Journal of Psychiatry, and others. Jon E. Grant is a Professor of Psychiatry and Behavioral Neuroscience at the University of Chicago where he directs the Addictive, Compulsive and Impulsive Disorders Research Program. They are co-authors of Clinical Guide to Obsessive Compulsive and Related Disorders.

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Image Credit: Person washing his hands. Photo by Lars Klintwall Malmqvist. Public domain via Wikimedia Commons.

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By Donald W. Black

For many years I have pondered the mental state and motivations of mass shooters. The tragic events in Newtown, CT this past week have brought this to the fore. Mass shootings have become everyday occurrences in the United States, and for that reason tend not to attract much attention unless the circumstances are especially heinous, such as this instance in which the victims were young children. We are all left wondering what can be done. While the attention span of the general public and the media is usually a matter of nanoseconds, this mass shooting seems different, and I hope will lead to positive policy changes. This tragedy presents an opportunity for our leaders to step up to the plate and lead and, one hopes, implement rational gun control legislation most of us agree is necessary.

But back to the shooters. As a psychiatrist with an intense interest in bad behavior, I expect that discussions will center on mental health issues which many believe motivate the shooters. I am intensely interested in these “issues” because, to me, the main issue that keeps coming up is that of psychiatric diagnosis. Everyone seems interested in the possibility of a psychiatric diagnosis, because it suggests that we might “understand” the shooter, and this may lead to better identification of future shooters, and both improved treatment and prevention.

But will the presence of a psychiatric diagnosis improve our understanding? Probably not, because — at least in the cases we know about — the apparent psychiatric diagnosis runs the gamut. Some shooters appear to have schizophrenia, others a depressive disorder, and still others a personality disorder, as has been alleged in the case of Adam Lanza. While we seem able to understand that a “crazy” person out of touch with reality might carry out an otherwise senseless act, the thought that someone who is not psychotic carrying out such an act is very unsettling. How could a person who is not psychotic behave this way? For example, depressed persons are by and large not psychotic, yet some will — in the context of being hopeless and suicidal — want to take others with them: spouses, children, etc. More typically, while planning to harm themselves, most depressed persons have no desire to hurt anyone else.

What about the non-psychotic people with a personality disorder? The Diagnostic and Statistical Manual of Mental Disorders — a compendium of psychiatry’s officially recognized disorders (about to come out in its 5th edition) — lists ten personality disorders; the most relevant to our discussion is antisocial personality disorder. This disorder is quite common (up to 4.5% of the population) and causes all manner of problems because the antisocial person always seems to be in trouble with the law, their spouses and families, or their employers.

The term antisocial is almost always misunderstood and is often construed to mean ”shy” or “inhibited,” yet in a psychiatric sense the term suggests rebellion against society. My profession has done a poor job in educating the general public about the disorder and for that reason it remains under the radar screen. (An older term that seems more entrenched is sociopathy.) In the DSM, the diagnosis rests on the person having three or more of seven symptoms (such as deceitfulness, impulsivity, irritability and aggressiveness, etc). Perhaps the most important is “lack of remorse,” which occurs in about half of those diagnosed antisocial. This is what allows the antisocial person to hurt, to mistreat, or even to kill others. These are the “psychopaths” we read about and fear. (Psychopathy is at the extreme end of the antisocial spectrum of behavior.) Few antisocials are killers, but many of today’s mass shooters would fit the description of antisocial personality disorder. I don’t know if Adam Lanza would, but as we peel back the layers of his personal history, we might find that he does.

We don’t know what causes antisocial personality disorder, but like many disorders it probably results from a combination of genetic and environmental factors. I have argued for many years that the federal government needs to direct more funds to investigating its causes and developing effective treatments. Despite its high prevalence and the fact that it contributes to so much of society’s ills, the government has shown little interest in funding research on the disorder. The National Institutes of Health RePORTER website lists only two projects in which the term “antisocial” appears in the title and only five in which the terms “psychopathy” or “psychopathy” are used. Considering that NIH funds literally thousands of projects, this can only be considered hopelessly inadequate. Overcoming this resistance to research on antisocial personality disorder and related conditions must be a priority.

We need wide-ranging projects to explore the origins of antisocial behavior and search for methods to change its course. Geneticists should investigate the mechanisms underlying antisocial behavior, locating genes that might predispose individuals to antisocial behavior and determining how these genes function. Neuroscientists should pinpoint brain regions or networks linked to antisocial behavior and identify biochemical and physiological pathways that influence its expression. A range of treatments — both drugs and therapy — need to be developed, tested, and refined.

Will these steps help us understand the conundrum of the mass shooter? Will they allow us to treat antisocial persons and prevent youth with antisocial tendencies from developing a full-blown disorder? We can certainly hope.

Donald W. Black, MD is a professor of psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. He is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated (Oxford University Press, 2013).

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Obsessive Compulsive Disorder (OCD) is an often misunderstood anxiety disorder. It’s treatment of choice, a form of Cognitive Behavioral Therapy known as Exposure and Response Prevention (ERP), is likewise difficult to grasp and properly use in therapy for both consumers and their therapists. This is in part because of the counter-intuitive nature of ERP, as well as the subtle twists and turns that OCD can take during the course of treatment.

Dr. Allen Weg, a licensed psychologist, has perfected the art of storytelling and metaphor use as a way of explaining and employing ERP to his clients in therapy. He utilizes this same technique to train other therapists in the use of ERP for OCD. In this brief, entertaining video, Dr. Weg walks you through 3 of those stories, and introduces you to his book entitled, OCD Treatment Through Storytelling: A strategy for successful therapy, a collection of more than 50 such stories that he has developed over the last 25 years in his work with OCD.

Click here to view the embedded video.

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I was once in a meeting at work where we were trying to manage a runaway engineering project.

The various players were discussing this or that aspect when one of the more senior guys—and one who was pretty discouraged about the prospects of ever getting control of the project—said “and how do you plan to manage entropy?”

That stopped the conversation for a while.

Entropy is the tendency of things to disorder.

In a moment this will bring me to the comments of John Simpson the Chief Editor of The Oxford English Dictionary but first I’ll give you the etymology of entropy.

A guy named Rudolf Clausius is generally credited with coming up with the second law of thermodynamics. He was German physicist and in 1856 he refined the thinking on how matter behaves as relates to heat and disorder down to a mathematical formula.

He also invented a word for it, entropy from Greek and meaning “in turning” the turning being interpreted as “transforming”—as to disorder.

I don’t know what John Simpson has to say about entropy, but he recently had something to say about H. G. Wells.

Simpson pulled two quotes from the 1914 novel The World Set Free in which H. G. Wells makes a few predictions about the development of the English language. Almost 100 years on we can see how those predictions fared.

The first is that our vocabulary would swell. Wells predicted that the OED would be bursting with a quarter of a million words defined. Moreover, with all these new words, a person with a vocabulary of 100 years ago would have a hard time reading a newspaper; there would be too many words in there they’d never seen before.

It turns out that the author who wrote of time machines, invisibility and utopia was too conservative in his estimation of English.

The OED entered 2010 under the weight of almost 2½ times Wells’ estimate of word count. That’s 597,291words.

But what has that to do with entropy?

Wells also got his general direction right in predicting that English would become increasingly an international language. But he forecast more rules and regulation would be imposed on English.

The English language is very democratic. Words and their use flourish not by official approval but by popular usage. More users, more words, more creative usage.

Not exactly entropy but it got me thinking.

Ashley- Intern Extraordinaire

It is estimated that 1-3% of young adult women and one tenth that number of men suffer from the eating disorder bulimia nervosa, which involves binge eating followed by purging and feelings of guilt and shame. The goal of treatment is to unearth the factors that trigger such a disorder. The Treatments That Work series offers effective ways to combat various medical issues, and in Overcoming Your Eating Disorder: Workbook, by Robin F. Apple and W. Stewart Agras, patients are presented with ways to conquer bulimia nervosa and binge-eating disorders. The following excerpt talks about keeping a Daily Food Record, a method that allows patients to connect what they eat with how they feel.

Common Concerns About Keeping Records

Despite the value and usefulness of keeping food records, it is not uncommon to be somewhat hesitant about self-monitoring.

Perhaps you have used food records previously and were unsuccessful. Even if prior attempts to record your eating were ineffective, we encourage you to give record keeping another chance! We expect that you will find food records helpful when used as part of this treatment…

Maybe you think that closer examination of your eating problems will only make matters worse. You may feel that you already spend too much time thinking about eating anyway. But there are many reasons for becoming even more vigilant about your eating, particularly when your goal is to improve it. As explained, the process of keeping track of your eating, and also the product of record keeping (a long-term food diary) can bring substantial benefits. When you monitor your own eating behavior, you become more ware of the context in which your eating problems occur, particularly the thoughts, feelings, and situations that place you at “high risk” for binge eating and purging. By noting the association between these types of factors and the occurrence of binge-eating episodes, you will be better able to identify and anticipate these difficult, triggering situations and to work out strategies for avoiding or responding differently to them. Retrospectively, you will be able to learn from past problems and successes with your eating by reviewing the contexts in which these types of eating episodes tended to occur and the coping strategies you attempted to implement. Noting long-term patterns will help you view your eating problems as more predictable and controllable…

The Importance of Timely Recording

Many individuals with bulimia or binge-eating disorder often acknowledge having a poor memory for the details of their binge episodes. They commonly describe “spacing out” while eating; even those who remain “aware” tend to reconstruct their eating patterns in a manner that reflects a global, overly negative, and black-and-white thinking style (e.g., overestimating the amount of food consumed, exaggerating its effect on their body weight and shape, viewing any departure from rigid rules about what should and should not be eaten as gross violations, and interpreting a small overindulgence as having “ruined” the whole day). For these reasons, we recommend that the most effective strategy for recording food intake is to do so at the time of or as soon as possible after eating. The advantages to this are considerable. First, the information obtained is most accurate and least vulnerable to distortion or poor memory. Second, the food record, when used in this fashion, can serve as a tool for planning meals and snacks in advance. When used in this way, the Daily Food Record can actually prevent or reduce the extent of overeating and purging by fostering a sense of commitment to sticking with a regular eating pattern and healthy food selections. Third, looking back over your records can help correct the types of perceptual distortions just described (e.g., the sense that you overate or “blew it,” without actual data to support that feeling or impression). Reviewing your food record daily may help you stay focused on the positive, reminding you that you are still on track, even when you are ready to give up. Likewise, an accumulation of food records over time will provide data about your rate of progress and level of improvement during the course of treatment.

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Today we are excited to bring you Emily Martin a professor of anthropology at New York University. In her most recent book, Bipolar Expeditions: Mania and Depression in American Culture, (published by Princeton University Press), Martin guides us into the fascinating and sometimes disturbing worlds of mental-health support groups, mood charts, psychiatric rounds, the pharmaceutical industry, and psychotropic drugs. Charting how these worlds intersect with the wider popular culture, she reveals how people living with bipolar disorder are often denied the status of being fully human, even while contemporary America exhibits a powerful affinity for manic behavior. In the post below Martin look at how this is affecting American’s perception of mood disorders. Thanks to our friends at PUP for letting us know about this fascinating book!

What lies behind the recent explosion in the diagnosis of bipolar disorder among American children? There is much to wonder about, as we know from Time magazine’s 2002 cover, “Young and Bipolar;” and from a recent 60 Minutes segment, “What killed Rebecca Riley?” Four year old Rebecca is said to have died from an overdose of psychiatric medications given to her for her bipolar disorder. The New York Times had already reported the month before that the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003. Not long afterward, under the headline “Your Child’s Disorder May be Yours, Too,” The Times reported that parents are struggling with whether to acknowledge aspects of their own behavior that are consistent with mood disorders in order to help their children feel they have “fellow travelers.” Behind these stories lie powerful cultural changes in how Americans regard their moods.

Bipolar disorder is becoming not only a disability but also an asset. Because of the creativity of their manic states, larger than life figures like Robin Williams and Ted Turner are frequently described as “bipolar.” Depression, at the other end of the mood spectrum carries a different load of associations. If mania comes to signal success in the competitive, sped-up global economy, depression signals the opposite: the failure to be productive. What interests me as an anthropologist is that cultural values very specific to our society are carried along with the diagnosis of a mood disorder.

For bipolar disorder, the our cultural fantasy is that as depression can be made to wither away altogether, the high energy of the manic phase can be tamed or optimized, so that individuals can succeed and economies grow. The growing numbers of psychopharmaceutical drugs are what allow contemporary doctors to give a patient a diagnosis of mood disorder and treat it, rather than (as in earlier historical periods) lay the patient’s problems at the feet of his or her temperament or character. At a meeting of the American Psychiatric Association, I met a young doctor who practiced in a well-known hospital near Hollywood. When he heard about my research, he became quite interested and offered me this experience.

Where I work, we get a lot of Hollywood comedians coming in. They are manic depressives. There are two important things about this: first, they do not want their condition publicized, and second, their managers always get involved in the details of their treatment. The managers want the mania treated just so. They do not want it floridly out of control, but they also absolutely do not want it damped down too much.

He felt he was being called upon to optimize his patients’ moods (for the theatrical profession and for the particular kinds of creativity it requires) through proper management of their drugs. Listening as an anthropologist, I began to feel uneasy about the prospect of extending the optimization of psychotropic drugs to suit other kinds of employment and people in other age groups. What would happen if optimizing states of mind were extended, as the DOD hopes, to soldiers on combat duty? What are the implications of extending the use of powerful psychotropic drugs to treat children whose behavior causes problems at home or school? A number of factors have been blamed for the rising statistics of bipolar disorder in children: improved treatments or more knowledgeable diagnosis by doctors. But the need for treatment (real as the need may be and helpful as the treatment may be in some cases) cannot be separated from values in our cultural environment that associate some moods with success and others with failure. A broader conversation about the cultural environment in which rates of bipolar disorder are rising would enrich our understanding of what it means to be bipolar – for children and adults alike –today.

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By Kirsty OUP-UK

Quotations are an endless source of information and amusement. In celebration of the new edition of The Oxford Dictionary of Modern Quotations, editor Elizabeth Knowles has kindly written the piece below, taking us through the most engaging parts of working on a dictionary of quotations.

One of the most fascinating parts of working on a dictionary of quotations is the sense of encountering a wide range of distinctive personalities: what the 14th-century William Langland might have described as ‘a fair field full of folk’. Many people come to life through their own words. Marlene Dietrich commented ‘Glamour is what I sell in my act, and it costs plenty. It’s my stock-trade.’ (more…)

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