Recognizing OCD at School by Aureen Pinto Wagner, Ph.D.

School-aged children often have rituals that are normal and playful, which can make it harder to spot OCD rituals. Further, youngsters with OCD often hide their OCD rituals in school because they are embarrassed about them. They do not want peers or teachers to notice their odd or unusual behaviors. Unlike normal rituals, OCD rituals tend to be extreme, unusual or bizarre, and upsetting to the child. The child feels forced to do them, gets very upset when interrupted, and feels out of control. They also interfere with the child’s functioning at school.

The behaviors described below may be clues to OCD. However, none of them suggest a definite diagnosis of OCD by themselves. A youngster who shows these behaviors for over a month may need to be evaluated by a qualified mental health professional.

• Over-focus on neatness. Lining up, ordering or arranging items on desks, in backpacks or lockers repeatedly. • Wanting to complete assignments “perfectly,” checking and re-doing it. • Sloppiness or carelessness in completing assignments, which is not typical for the child. • Erasing repeatedly until the paper has holes in it, the ink is smudged and the writing or drawing is illegible. • Reading letters, words or sentences repeatedly, repeating syllables until they sound right. • Filling in scantron sheets very carefully; getting upset if they are not perfectly filled in. • Very slow and deliberate work, resulting in incomplete assignments. • Incomplete assignments or homework, although the child is capable of doing them • Checking homework, backpack, lockers, pockets, or under the desk and chair repeatedly, ensuring that locks

and zippers are fastened. • Frustration or anger when things are disorganized, when interrupted, or when routines change unexpectedly. • Refusal to go to school, or being late regularly due to need to complete rituals at home. • Asking the teacher or other students the same questions repeatedly, even though the child knows the answer • Frequent trips to the bathroom, either to use the toilet or wash hands • Sore, chapped or bleeding hands. • Refusing to touch others’ books, pencils, touch the ball in gym etc. • Getting upset if others touch his or her belongings, wanting to clean or wipe them off. • Counting or focus on lucky and unlucky numbers. • Sudden avoidance of familiar things or reluctance to try new things • Odd behaviors such as walking in specific patterns through doorways, counting tiles or syllables, touching or

tapping in symmetry or sitting and standing repeatedly • Opening doors, lockers, desks, or books with elbows or with tissue in hand, holding hands in the air to avoid

physical contact, refusal to shake hands or share pencils or other supplies. • Secretive or unusual behaviors for which there is no obvious explanation.

Source: http://kids.iocdf.org/ocdinkids/personnel/ocd_in_school.aspx (accessed 12/3/14)

 

What is Body Dysmorphic Disorder (BDD)?

• Thinking too much about an imagined or slight flaw in a person’s own looks. (APA, 2000). If there is a slight flaw, the person’s concern is extreme.

• These unhappy feelings are consuming. These feelings cause harmful beliefs and attitudes that affect thoughts, emotions and behaviors. These can then harm all areas of a person’s life, such as their social activities and job.

• No other mental disorder, for example eating disorders, cause these consuming feelings. What are the common signs and symptoms of BDD?

• Fixation and thoughts about appearance • Mirror checking-Spending too much time staring in a mirror/shiny surface at the real or imagined

flaw • Avoidance of mirrors/shiny surfaces • Their belief is very strong even if evidence does not support it (this is also called Overvalued

Ideation or OVI) • Covering up the “afflicted area.” (e.g. hats, scarves, make-up) • Repeatedly asking others to tell them that they look okay (also referred to as ‘reassurance

seeking’). • Frequent unnecessary appointments with medical professionals/surgeons • Repeated unnecessary plastic surgery • Compulsive skin picking. Often, nails and tweezers are used to remove blemishes/hair. • Avoiding social situations, public places, work, school, etc... • Leaving the house less often or only going out at night to prevent others from seeing the “flaw”. • Keeping the obsessions and compulsions secret due to feelings of shame. • Emotional problems, such as feelings of disgust, depression, anxiety, low self-esteem, etc.

How do you tell the difference between being unhappy with a part of your appearance and BDD? Many people are unhappy with some part of the way they look, however, this is on a continuum. When thinking about the body part becomes incapacitating and interferes with the person’s quality of life and functioning, then the person is diagnosed with BDD. This stress can appear in many ways, but often through anxiety and depression. What parts of the body are the focus of BDD?

• Most often, the flaw or slight imperfection is located on the head or face (e.g. hairline, nose, acne, neck, etc.)

• However, any body part may be the focus. Some common areas include: arms, legs, stomach, hips, etc.

Who struggles with BDD and when does it start? BDD can affect anyone. However, body image concerns most commonly begin in adolescence when children begin to compare themselves to their peers. Some research suggests that BDD may affect at least 1 in 200 people, however no exact number is known. Are only women diagnosed with BDD? No, an equal number of men and women are diagnosed with BDD. Men are often concerned with their hairline or how muscular they are.

Can BDD get worse as the person ages? Yes. Often, if a person struggles with image concerns at a young age, they become more unhappy as they struggle with the physical changes that come with age (gray hair, loss of hair, wrinkles, weight gain, etc.). What are the effects of BDD? The stress of BDD can be very severe. The stress can lead to an unending search of unnecessary medical and surgical procedures, avoiding daily activities, avoiding job duties, avoiding social situations, suicidal thoughts and attempts, etc. Research shows that up to 80% of people with BDD think about or try to commit suicide. Are BDD and obsessive compulsive disorder (OCD) related? Recent research suggests that BDD is an "obsessive-compulsive spectrum disorder.” This is because there are both obsessions and compulsions. Obsessions are unwanted thoughts or images that cause anxiety and distress. Compulsions are repeated mental or behavioral acts done to reduce the anxiety caused by obsessions. With regard to BDD, obsessions appear as unwanted negative thoughts about appearance that lead to compulsions. These compulsions usually involve disguising or coping with the imagined flaw. Can BDD be treated? Yes. Cognitive Behavior Therapy (CBT) is used to challenge the beliefs that appearance can be perfect and that others focus on those flaws. Exposure and Response Prevention (ERP), using both thoughts and real life situations, are also used to prove whether these thoughts are accurate. For example, a girl who is concerned with a slight bulge in her stomach may be asked to go in public wearing a tight fitting t-shirt then observe how many people are actually staring at her stomach. Another technique may be to take a picture of her in the tight fitting shirt and have people rate her attractiveness. Does plastic surgery cure BDD? People with BDD often try to “fix” the flawed body part with surgery. However, not only may it cost a lot of money, but, even with surgery, people with BDD, will never be satisfied with the area of concern. Are there medicines that can help reduce BDD? Usually, a recommended treatment plan for BDD would be a combination of CBT and medicine. Medicine may aid in decreasing symptoms of depression and anxiety that commonly accompany BDD. The most common medication prescribed for BDD are anti-depressants, specifically Selective Serotonin Reuptake Inhibitors (SSRI). Where can I find more information? International OCD Foundation (www.ocfoudation.org) BDD Central (www.bddcentral.com) Association for Behavioral and Cognitive Therapies (www.aabt.org) National Alliance on Mental Illness (www.nami.org) National Mental Health Association (www.nmha.org)

Authors: Fugen Neziroglu, PhD and Jill C. Slavin, PhD, BioBehavioral Institute, Great Neck, NY.

Obsessive Compulsive Disorder in Children and Teenagers What is obsessive compulsive disorder (OCD)? OCD is an anxiety disorder that consists of obsessions and compulsions. Obsessions are unwanted ideas, thoughts, images or urges that are unpleasant and may cause worry, guilt or shame. Compulsions, also called rituals, are behaviors the child feels he or she must perform repeatedly to reduce the upsetting feelings or prevent something bad from happening. To be diagnosed as OCD, these behaviors must be time-consuming and interfere with the child’s daily life. What kinds of obsessions do children and teenagers have? Children may have worries about germs, getting sick, dying, bad things happening, or doing something wrong. Feelings that things have to be “just right” are common in children. Some children have very disturbing thoughts or images of hurting others, or improper thoughts or images of sex. What compulsions or rituals do children and teenagers have? There are many different rituals such as washing and cleaning, repeating actions until they are just right, starting things over again, doing things evenly, erasing, rewriting, asking the same question over and over again, confessing or apologizing, saying lucky words or numbers, checking, touching, tapping, counting, praying, ordering, arranging and hoarding. How is OCD different from other childhood routines? It is normal for many young children to have routines at mealtime, bedtime or when saying goodbye. These common routines lessen as children get older. For children with OCD, the routines continue past the appropriate age, or become too frequent, intense or upsetting, and begin to interfere with the child’s daily life. How common is OCD among children and teenagers? About half a million children in the United States suffer from OCD. This means that about one in 200 children, or four to five children in an average-sized elementary school, and about 20 teenagers in a large high school may have OCD. Is OCD in children and teenagers different from OCD in adults? Children experience some of the same obsessions and compulsions as adults. One third of adults with OCD developed their symptoms when they were children. Unlike adults, children may not always recognize that their symptoms are senseless or that their compulsions are excessive. They also involve their family members in their rituals. For instance, they may insist that everyone in the family wash their hands a certain way, or that their parents check their homework repeatedly. How does OCD affect children and teenagers? OCD can make daily life very stressful for children. Rituals usually take a lot of time, and children often are late for school or activities. This often results in tension or arguments in the family. Children are unable to enjoy time with friends or have fun when OCD takes up all their spare time. At school, obsessions and rituals such as checking, erasing and re-doing assignments affect attention and focus, completion of tasks and school attendance. Older children and teenagers may worry that they are crazy and work hard to hide their OCD from others. Getting through a day with OCD can be exhausting. Children with OCD often have lengthy bedtime rituals that they feel must be completed. They therefore go to bed late and are tired during the day. All this stress may make them sad, angry or explosive.

2 How does OCD affect families? Home life often suffers when a child has OCD. At first, parents may be confused or frustrated by their child’s odd behaviors. They may become scared when their child gets very upset and cannot seem to stop the rituals. Children with OCD may make their families take part in their OCD in many different ways: They often look for reassurance by repeatedly ask their parents the same questions, and demanding answers each time. They may want help from parents and siblings in completing their rituals. They may insist that parents and siblings follow their OCD rituals as well. They may get very angry if they do not “get their way.” All of this is very stressful for the family, who may feel that they cannot relax and that home life is very tense. Parents may feel that they must change the family’s daily routine or give in to the child’s demands to prevent the child from becoming too anxious or angry. Parents may go through many different feelings including fear, frustration, anger, guilt and sadness. They often worry about whether their child will get well again, and what their future might be like. Can OCD in children and teenagers be treated? Yes, OCD in children can be effectively treated. Although there is no cure for OCD, cognitive-behavioral therapy (CBT) and medicines are effective in managing the symptoms. Experts agree that CBT is the treatment of choice for children with OCD. Whenever possible, CBT should be tried before medicine with children. What is CBT and how does it work? Using a CBT strategy called exposure and response prevention (ERP), children with OCD can learn that that they are in charge, not OCD. They can learn to do the opposite of what the OCD tells them to do, by facing their fears slowly in small steps (exposure), without giving in to the rituals (response prevention). ERP helps them find out that their fears don’t come true, and that they can habituate or get used to the scary feeling, just like they might get used to cold water in the swimming pool. What medications help children with OCD? The medicines used to treat OCD in children are antidepressants called selective serotonin reuptake inhibitors (SSRI’s). Medicines should only be considered when the OCD symptoms are moderate to severe. There is no one “best” medicine for any child because the medicines affect each person differently. Your child’s doctor will decide which medicine to try. The medicines take some time to act, so it is important to wait for 10-12 weeks for the full effect. Although medicines may decrease OCD, the symptoms often return when the child stops taking medication. I think my child may have OCD. What should I do? You have already taken an important step by educating yourself and reading this sheet. If the OCD symptoms upset your child and interfere with his or her everyday life (school, friends, behavior, etc.), talk to your child’s pediatrician or seek an evaluation with a qualified mental health professional such as a psychologist, psychiatrist or social worker. You are your child’s best advocate. It is important to find a CBT therapist or clinic with a good reputation for treating children with OCD, and who will involve you in your child’s treatment as well. If you are looking for medication treatment, it is also important to find a doctor who is experienced in treating children with OCD. You can find listings of professionals at www.ocfoundation.org, www.abct.org and www.adaa.org. However, always ask questions to make sure that the therapist or doctor you are considering is experienced in treating children with OCD. Author: Aureen Pinto Wagner, Ph.D., Clinical Associate Professor of Neurology, University of Rochester School of Medicine & Dentistry; Member, Scientific Advisory Board of the International OCD Foundation

Copyright © 2009 International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801 http://www.ocfoundation.org

MYTH: WE ARE ALL “A LITTLE BIT OCD” AT TIMES.FACT: OCD is not a personality quirk or a character trait — it is a very real mental health condition that affects

about 2 to 3 million adults, and half a million youth, in the US alone. While many people can have obsessive or compulsive traits, OCD stands for obsessive compulsive disorder, and people who are diagnosed with OCD cannot simply “turn it off.” Research has shown that their brains are wired differently than the brains of people without OCD, and as such OCD strongly influences their thoughts and actions.

MYTH: OCD IS NOT THAT BIG A DEAL, PEOPLE JUST NEED TO RELAX AND NOT WORRY SO MUCH.FACT: Having OCD is not simply an overreaction to the stresses of life. While stressful situations can make things

worse for people with OCD, they do not cause OCD. People with OCD face severe, often debilitating anxiety over any number of things, called “obsessions.” This level of extreme worry and fear can be so overwhelming that it gets in the way of their ability to function. To try to overcome this anxiety, people with OCD use “compulsions” or rituals, which are specific actions or behaviors. These compulsions are not activities a person with OCD does because they want to, but rather because they feel they have to in order to ease their fears. OCD is not about logic — it is about anxiety and trying to get relief from that anxiety.

MYTH: OCD IS JUST ABOUT HAND-WASHING, CLEANING, AND BEING NEAT.FACT: Triggers related to cleanliness and symptoms related to washing make up only a small part of the range

of OCD triggers and symptoms. People with OCD can have obsessions related to a wide variety of things, including losing control, hurting others, unwanted sexual thoughts, and many more. Similarly, the anxiety caused by these obsessions can be lessened by different compulsions, such as “checking” (e.g., re-checking door locks, repeatedly making sure the oven is off), “repeating” (e.g., doing the same action or ritual over and over to be sure it was done “correctly”), and “counting” (e.g., doing things in certain numbers, counting items to certain numbers).

MYTH: PEOPLE WITH OCD ARE JUST “WEIRD,” “NEUROTIC,” OR “CRAZY” AND THERE IS NO HOPE FOR THEM TO EVER LEAD HAPPY, FUNCTIONAL LIVES.

FACT: With proper treatment, it is very possible for people with OCD to lead full and productive lives. Many people respond positively to behavioral therapy and/or medication. Specifically, Exposure and Response Prevention or ERP is considered the first-line treatment for OCD. Additionally, medication (such as anti-depressants like SSRIs) may also be recommended for people with OCD. Family therapy can also be very beneficial since family members (including parents, siblings, and spouses) often play a major role in recovery. Finally, many individuals report that support groups are very helpful. Support groups provide a safe, understanding place for people with OCD to feel less alone, as well as to teach and learn from their peers. People with OCD use one or several of these options to help them manage their OCD, as well as the support and understanding of their loved ones.

HOW CAN I HELP?• Stigma is one of the biggest problems faced by people with OCD, but oftentimes,

people don’t realize that their words or actions are stigmatizing or trivializing the suffering of those with OCD. The next time you hear someone say that someone or something is “so OCD,” engage them in conversation about what OCD really means and why what they’re saying is dismissive and inaccurate.

• Educate yourself about OCD, and work to raise awareness in your community however you might feel comfortable.

• Visit the IOCDF website or follow us on Facebook or Twitter to learn more ways to help.

RESEARCH.RESOURCES.

RESPECT.

iocdf.org

@IOCDF

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“I’m soooo OCD” + Other Common Myths About Obsessive Compulsive Disorder

Skin Picking Disorder Fact Sheet What is skin picking disorder? Skin picking disorder is a disorder where a person:

• Picks their skin over and over again, AND • The picking is often or bad enough to cause tissue damage AND • It causes a lot of distress and/or problems with work, social, or other daily activities.

People with skin picking disorder can (and often do) have other psychological symptoms, like depression and anxiety. Do all people who pick their skin have skin picking disorder? No. Research has shown that many people pick at their skin from time to time. It is not uncommon for a healthy person to occasionally pick at pimples, scabs, or even healthy skin. Skin picking is not considered a disorder unless it is often and/or bad enough to cause significant distress or problems in other areas of life. Also, other types of health problems like skin conditions, mental retardation, and even drug use/withdrawal may cause people to pick at their skin at times. However, people with primary skin picking disorder do not pick at their skin only because they have these other problems. What is a typical skin picking disorder episode like? Where, when, and how people pick at skin varies. People can pick skin from one or more parts of the body. Common areas include: face, head, cuticles, back, arms and legs, and hands and feet. People most often pick skin with fingers and fingernails, but people also remove skin in other ways, e.g., by biting, or picking with tools like tweezers or scissors. People pick for different reasons. People may pick out of habit or boredom, and, at times, may not even be aware that they are picking. People may also pick in an attempt to cope with negative emotions (e.g., anxiety, sadness, anger) and/or in response to feelings of mounting stress and tension. While picking, people may feel relief. However, feelings of relief are often followed by feelings of shame or guilt. After picking, people discard their skin in different ways. Some people discard the removed skin in the trash or on the floor. Some people eat skin after they have picked it.

Who suffers with skin picking disorder? Skin picking disorder may affect as many as 1 in 20 people. Although it occurs in both men and women, research suggests that skin picking disorder occurs much more often in women. Skin picking can begin in childhood or adulthood.

What causes skin picking disorder? The exact causes of skin picking disorder are unknown. It may be that both biological and environmental factors play a role in skin picking disorder. How is skin picking disorder related to OCD? Skin picking disorder is currently classified as an impulse control disorder. Skin picking disorder is also sometimes referred to as a “body focused repetitive behavior.” It is also sometimes referred to as an "obsessive compulsive spectrum disorder" (or “OC spectrum disorder”) because it shares features of OCD. For example, people with skin picking disorder pick skin over and over again, often in response to recurrent thoughts about or urges to touch or pick skin. In this way, symptoms of skin picking disorder are similar to those of OCD, which is characterized by urges to do repetitive behaviors (rituals) in response to other types of recurrent thoughts, images, and impulses. Skin picking disorder also shares similarities with other OC spectrum disorders, like trichotillomania (repetitive hair pulling disorder), tic disorders, and body dysmorphic disorder (BDD) (an OC spectrum disorder characterized by repetitive thoughts about appearance-related concerns). People with skin picking disorder are more likely than people without it to have OCD and other OC spectrum disorders. What are the effects of skin picking disorder?

Skin picking disorder can hurt a person emotionally, physically, and socially. In addition to feeling shame and embarrassment, people with skin picking disorder can have other psychological problems like depression and anxiety. Skin picking disorder can also interfere with social life, school, and/or work. Mild to severe pain during or after picking; sores, scars, disfigurement; and other medical problems like infections can also occur. In extreme cases, skin picking can cause sores severe enough to require surgery. Are there treatments for skin picking? Yes. Although more research is needed on treatments for skin picking disorder, some research suggests that cognitive behavioral therapy (CBT) may help with skin picking disorder. Acceptance and commitment therapy (ACT) may also be helpful in treating skin picking disorder. Research also suggests that skin picking may be effectively treated with medications such as SSRI’s (selective serotonin reuptake inhibitors). SSRI’s include: fluoxetine, fluvoxamine, and escitalopram. Some research suggests that the anti-seizure medicine lamotrigine may also be helpful in treating skin picking disorder. Unfortunately, because many people do not know that there is help for skin picking disorder, many people with the disorder continue to suffer with it.

More Information: The Trichotillomania Learning Center www.trich.org Stop Picking.com www.stoppicking.com

Author: Jeanne M. Fama, Ph.D., Massachusetts General Hospital

Copyright © 2010 International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801 http://www.ocfoundation.org

Tourette Syndrome

What is Tourette Syndrome? Tourette Syndrome (TS), or Tourette’s Disorder is a childhood neuropsychiatric (mental and nervous system) disorder that involves multiple tics—repetitive sudden movements (motor tics) and vocal outbursts (phonic tics) that seem largely outside of the person’s control. TS is one kind of a spectrum of tic disorders that includes transient tics (tics of less than a year’s duration) and chronic tics (tics typically lasting more than a year.) TS affects each person differently. However, tics tend to occur many times each day (often in flurries), typically wax and wane in their severity, change in form over time, and may disappear for weeks or months before coming back. What are tics like? Tics vary greatly and can be very confusing. TS symptoms tend to emerge between five and eighteen years of age and often stop by early adulthood. They are often divided into four varieties:

• Simple motor - These tics are sudden, quick movements that involve a limited number of muscles and are usually repetitive. Examples: eye blinking, grimacing, shoulder shrugging and head jerking.

• Simple phonic - These tics are when sounds are made. Examples: throat clearing, coughing, yelping or sniffing.

• Complex motor – Movements that last longer and seem more purposeful. Examples: smelling things, jumping, touching or hitting others and self-injurious behaviors.

• Complex phonic - Tics involve repeating sounds or phrases nonsensically. Examples: emitting words or phrases out of context, counting things out loud, or more rarely, vocalizing socially unacceptable words.

What other disorders are associated with TS? While many people only have tics, it is not unusual for people with TS to have other disorders (i.e. “TS Plus”). Some of the common problems associated with TS are obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), learning disabilities, impulsive control difficulties, and anxiety and mood disorders. Who gets TS? TS was once thought to be rare, probably in part because health professionals were unfamiliar with the disorder. Many cases still go undiagnosed, but it is estimated that 100,000 Americans have severe forms of TS and that as many as one in a hundred show milder forms. It occurs in all races and ethnic groups, with males affected three to four times more often than females. Why do people get TS? The cause of TS is unknown, but research suggests that abnormalities in certain parts of the brain and possibly brain chemicals (neurotransmitters) involved in communication among brain cells are involved. While genetic studies show that there may be an increased risk toward tic disorders in the families of TS sufferers, recent

evidence has pointed to a possible link with autoimmune abnormalities following infectious disease (e.g. PANDAS-- Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection). How is TS diagnosed? Experienced health professionals make the diagnosis by considering the person’s symptom profile, individual history, and family history. There are currently no medical or psychological tests that can diagnose TS. A range of tests such as an electroencephlogram (EEG), magnetic resonance imaging (MRI), computer assisted tomography (CAT scan) or blood tests may be done to identify or rule out other conditions that may be confused with TS. What is the prognosis? The natural course of TS varies from individual to individual, however tics tend to occur many times each day (often in flurries), typically wax and wane in their severity, often change in form over time, and may subside for weeks or months before reappearing. There is no cure for TS. The focus of treatment is on identifying and managing symptoms. Many cases of TS are mild and do not require treatment. TS symptoms tend to improve as individuals reach their late teens and early twenties. For some, disruptive tics can continue into adulthood and there are no reliable ways to tell how the disorder will progress in any one case. For many, disorders frequently co-occurring with TS, such as OCD, depression, ADHD and sleep disorders may cause more problems than the tics themselves. What treatments are available? A variety of treatments can help reduce problems from tics. These include: drug treatment and cognitive behavior therapy (CBT). Because there is a range of medicines that has been found to control TS symptoms, and because people react differently to medicines, drug treatment is best placed in the hands of doctors with plenty of experience with TS. CBT uses learning-based methods designed to increase awareness of tics, stop or lessen tics, and manage stressors that may make tics worse. However, treatment for disorders associated with TS, such as OCD and ADHD, may be a higher priority than treatment focused on management of tics. What else helps individuals with TS? Education, reassurance and support are extremely helpful to those with TS and their families. Better communication with families, school personnel and employers about TS can help with effective management of the disorder. The more people are educated about TS, the less social stigma exists. Where can I find further information and help? National Tourette Syndrome Association (www.tsa-usa.org) Tourette Syndrome Plus (www.tourettesyndrome.net) Tourette Syndrome Online (www.tourette-syndrome) Author: Charles S. Mansueto, Ph.D., Behavior Therapy Center of Greater Washington

Copyright © 2009 International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801

http://www.ocfoundation.org

Trichotillomania Fact Sheet

What is Trichotillomania? Trichotillomania is also known as compulsive hair pulling. A person can be diagnosed with trichotillomania if:

1. The repeated pulling out of one’s hair results in noticeable hair loss, and 2. There is an increasing sense of tension immediately before pulling out the hair or when

attempting to resist the behavior, and 3. There is pleasure, satisfaction, or relief when pulling out the hair, and 4. The condition is not caused by another mental or medical condition, and 5. The condition causes significant distress or interference in one’s life.

What causes Trichotillomania? There can be different causes of this condition; however, it is believed that an increased genetic risk, or other biological factors play a significant role. Are there certain ages that this condition tends to begin? Most individuals tend to start pulling their hair during childhood or adolescence, but it can start at any age including as an infant or in pre-school. Where are the common parts of the body that people pull from? Pulling can occur on any part of the body, however, the most common are:

• Scalp • Eyebrows • Eyelashes • Beard • Pubic area

When do people tend to pull their hair? Hair pulling can occur at any time, whether sitting in a classroom or at a desk at work. However, the most common times tend to be in downtimes such as the following:

• Watching TV • Laying in bed • Sitting at the computer • Sitting at a stop light • Reading a book

Are there certain people who are more likely to pull their hair?

o In children, boys and girls are equally affected. o In adults, trichotillomania appears to be more common in women than men. It is

unclear whether this represents those that are actually affected by the condition, versus those who are seeking treatment.

How can one be sure that the pulling is not caused by another condition? This could be ruled out by seeing a skin doctor (dermatologist) to ensure that there are no other skin conditions, for example on the scalp, that could be causing the pulling to create relief. It is also important that a primary care doctor is seen to ensure that there are no other conditions that could be causing the pulling.

Are there certain things that make Trichotillomania worse? Stress can cause hair pulling to get worse. Worries about a pending exam, financial problems, relationships, problems at work, etc. can also make the pulling worse. It is also important to note that while these examples represent what are called “negative” stressors, there can also be “positive” stressors. For example, getting married, buying a home or car, or planning a vacation.These situations can cause anxiety, and consequently stress on the body, resulting in the potential for increased pulling.

What is the treatment for Trichotillomania? A combination of education, medication, and behavior therapy tend to be the most effective forms of treatment. Each individual will need to be evaluated to determine the best protocol depending on their circumstances. Behavior therapy includes “Habit Reversal Training,” which is designed to increase the person’s awareness into the triggers, and create what are called “competing responses” to interrupt the pulling response.

What are some of the other effects that hair pulling can have? Depending on the degree of pulling, this condition can cause severe hair loss which may result in the need to cover up bald patches with hats, hair pieces and/or wigs. When one is pulling, there can also be an experience of shame and/or embarrassment, since many of those who have this condition feel out of control in their ability to stop. The act of pulling and the time involved in this behavior itself can also result in being late to work, school, or other social events, leading to feelings of depression and/or isolation.

Does the “mania” part of the word Trichotillomania mean that they are manic, as in a Bipolar Disorder? No. Bipolar Disorder falls under the category of a mood disorder, and is no way connected to trichotillomania. Trichotillomania falls under the category of an Impulse Control Disorder.

More Information:

The Trichotillomania Learning Center www.trich.orgStop Picking.com www.stoppicking.com

Author: Robin Zasio, Psy.D., LCSW, The Anxiety Treatment Center of Sacramento

Copyright © 2009 International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801 http://www.ocfoundation.org

PANDAS Fact Sheet

What is PANDAS? • The term ‘PANDAS’ is short for ‘Pediatric Autoimmune Neuropsychiatric Disorder Associated with

Streptococcus’ (The word streptococcus is often shortened to ‘strep’). • A child can be diagnosed with PANDAS when:

o Obsessive Compulsive Disorder (OCD) or tic symptoms suddenly appear for the first time, OR

o The symptoms suddenly get much worse, AND o The symptoms occur during or after a strep infection in the child.

• PANDAS is caused by the body’s immune reaction to strep, not the infection itself (Swedo & Grant, 2005). When an infection happens, the body’s immune system makes a variety of proteins to help fight the bacteria. Some of these proteins are called antibodies and can be clinically measured. The exact way that causes the neuropsychiatric symptoms (OCD, tics, etc.) is not known.

• Other immune triggers have been also reported to worsen OCD and tics (like Lyme’s disease, influenza, mycoplasma, etc.) and because the connection of the immune system to the neuropsychiatric symptoms is not fully understood, little is known about the best treatments (which may be different from other kinds of OCD treatment.) Currently, there are no scientifically approved evaluation and treatment protocols leaving clinicians and parents guessing at the best options for having these children assessed.

Diagnosing PANDAS: 1. Children with PANDAS are initially diagnosed with Obsessive Compulsive disorder or a tic disorder.

OCD and tic symptoms in PANDAS are similar to those in the classic forms of childhood OCD and tic disorders (Murphy, Kurlan, & Leckman, 2010).

2. PANDAS first appears in childhood from age 3 to puberty. In addition to OCD or tics, these children may have some or all of the following symptoms: • Sudden unexplainable rages (also called emotional lability) • Personality changes • ADHD (Attention Deficit Hyperactivity Disorder) that is new or dramatically worse. • Anorexia (often because of a fear of choking, or fear of throwing-up) • Nervous system disorders such as tics or other rapid, jerky movements • Age inappropriate behaviors (such as bedtime fears/rituals, loss of impulse control) • Separation anxiety • Defensiveness caused from hyperactive senses (such as sensitivity to clothing, noise, light, taste,

etc.) • Noticeable decrease in handwriting or math skills • Frequent urination (especially when the child has an active infection)

3. Diagnosis of PANDAS should be discussed after symptoms first suddenly appear or severely worsen. Usually this change is severe and dramatic. Many parents can pinpoint a day or a week when behaviors changed.

4. In PANDAS children, a strep infection occurs before or at the time the OCD symptoms ramp up. Assuming the infection is adequately treated, the first symptoms generally improve within 4-6 weeks. The next OCD episode may last longer and may be triggered by a variety of immunological challenges such as another strep infection, or by other bacterial or viral infections (ear infections, sinusitis, pneumonia, meningitis, impetigo) making a diagnosis more difficult.

5. Lab Tests: • A throat swab (rapid and culture) to test for strep can be done when symptoms first appear.

• If the throat swab does not show any signs of strep, a blood test for an antibody called ASO (Anti-Streptolysin O) can also be done. Ideally, ASO at symptom onset of <2 weeks duration and again 4-8 weeks later will provide support of a streptococcal trigger if a fourfold rise in titers is observed. In children with symptom onset exceeding four weeks before obtaining laboratory measures, an elevated ASO titer will add support but not provide proof that tic or OCD symptoms resulted from a streptococcal infection as 'strep throat’ is very common in the school age in children. Due to the child's age and variation in response to the infection, a low blood level of ASO alone does not rule out PANDAS.

• Other medical assessments will depend on clinical history and severity of presentation but may include other laboratory tests, EEGs, echocardiograms, etc.

6. PANDAS is not the only immune system disease that may initially cause OCD to appear suddenly. Other disorders may need to be ruled out. They include: Lyme Disease, Thyroid Disease, Celiac Disease, Lupus, Sydenham Chorea, Kawasaki’s Disease, and acute Rheumatic Fever.

Treatment: • Strep infections are treated with antibiotics. • Cognitive Behavioral Therapy (CBT), specifically Exposure & Ritual Prevention (ERP) therapy, has

been shown to help PANDAS patients and their families (Storch, 2006). • Selective serotonin reuptake inhibitor (SSRI) medicines are also effective for childhood OCD (SSRIs

are standard medical therapies and many are FDA approved for childhood OCD). However, children presenting with PANDAS may be more sensitive to behavioral side effects (aggression, hyperactivity, sleep problems and even suicidal thinking) but may tolerate at smaller than usual starting doses. Some children with first episode OCD/PANDAS will have the symptoms improve gradually if the infection was treated. SSRI use should be discussed with a doctor in order to weigh the benefits against the risks.

• Consider having the child evaluated for fine motor deficits by an occupational therapist if handwriting or coordination skills have deteriorated.

• Ask for school accommodations as appropriate for ADHD, OCD, or fine motor skill symptoms. • For some patients with severely disabling symptoms following infections, use of antibiotics as a

prevention method may be considered (Snider, et. al., 2005). Future studies are required to develop guidelines for which PANDAS patients should receive this treatment. This is due to the concern that antibiotic use may lead to the evolution of drug-resistant germs, increased risk for allergic reactions and alterations in the body’s balance of healthy bacteria such as thrush and C. difficile infections.

Key Points • PANDAS is a proposed kind of OCD that occurs in childhood following the body’s reaction to

infection. • It is thought to be the body’s immune reaction to infection, not the strep infection itself that causes

symptoms. • A high blood level of a strep antibody alone does not confirm PANDAS. Nor can a low blood level

of a strep antibody alone rule out PANDAS. • PANDAS should be managed with early antibiotic treatment for streptococcal infections. Continued

symptoms can be treated with standard OCD treatments (cognitive-behavior therapy and/or SSRI medication).

• PANDAS symptoms will only stop once an infection is fully treated. Doctors should perform follow-up throat cultures and check family members before assuming an infection is no longer present.

Authors: Evelyn Stewart, MD, University of British Columbia, Vancouver, Canada Tanya Murphy, MD, University of South Florida, St Petersburg, FL

Copyright © 2010 International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801

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