Stress and Trauma Impacts OCD

Obsessive-compulsive disorder (OCD) is a long-term disorder where an individual experiences obsessions and or compulsions (U.S. Department of Health, 2022). Obsessions can be characterized as recurring and unwanted thoughts, urges, or fears (U.S. Department of Health, 2022). Commonly reported obsessions include: fear of contamination, harmful thoughts towards other individuals or themselves, and needing items to be in a symmetrical/perfect order (U.S. Department of Health, 2022). According to the U.S. Department of Health and Human Services compulsions are repetitive behaviors that the individual feels the need to perform in order to make the obsessions go away. Many feel the urge to excessively wash their hands or clean, arrange belongings in a specific order, or constantly check on items (U.S. Department of Health, 2022). These symptoms typically affect an individual's day-to-day life in terms of their work, relationships, and school. While the causes of OCD are still unknown, risk factors such as brain function, genetics, and environmental factors appear to be associated with OCD. However, recent studies have shown that stress and trauma have a significant impact on the onset of OCD. 

Stress has been found to influence the onset associated with OCD in many individuals. Childbirth complications, marriage, socioeconomic struggles, bodily injuries, and age-related reproductive changes have all been identified as stressors that can contribute to OCD (Murayama et al., 2020). Self-reported studies by individuals with OCD have shown that 25-67% of OCD patients have reported stressful incidents occurring prior to their onset of their OCD symptoms (Adams et al., 2018). Another study containing 281 OCD participants recorded that 172 (61.2%) of the participants expressed they experienced stressful life events prior to their diagnosis (Murayama et al., 2020). It has also been reported that individuals with OCD experience stressful events occurring 6 months and 12 months prior to their onset of the disorder (Adams et al., 2018). Similarly, those individuals who vocalized their experience with stress prior to their diagnosis also experienced cleaning and contamination-related obsessions related to those stressful events  (Murayama et al., 2020).

Trauma has also been identified as a factor which intensifies the severity and onset of OCD symptoms (Adams et al., 2018). Traumatic events may include: war combat, sexual assault, and violence. Other potential traumatic events, which are commonly associated with childhood-related trauma, include neglect, physical, sexual, or emotional abuse (Pinciotti et al., 2022 ). Individuals who have experienced traumatic events during their childhood were found to be 5 to 9 times more likely to meet the criteria for OCD in their adulthood. These childhood-related traumas have been associated with higher suicide risk, as well as more severe OCD symptoms (Pinciotti et al., 2022 ). There is also a correlation between expressed childhood trauma and other mental health-related disorders including; anxiety, depression, impulsivity, and attention deficit hyperactivity disorder (Pinciotti et al., 2022 ). In addition, in a study with 954 OCD patients, leaving a relationship was identified as a stressor that accelerated the progression of OCD (Murayama et al., 2020). Furthermore, there are findings that suggest that lifelong trauma is linked with a higher obsession with checking items and ordering/symmetry symptoms, while sexual trauma is related to higher rates of contamination and washing compulsions (Pinciotti et al., 2022 ).

Although extensive research is being performed to better understand the neurological mechanisms that are associated with OCD, there should also be more focus on understanding the relationships between OCD symptoms, stress, and trauma. Insight into these OCD-related factors can allow for more treatment options to be provided to OCD patients. More importantly, prevention methods can be developed to prevent the early onset of OCD and the development of this disorder when not associated with genetic factors. 

References

Adams, T. G., Kelmendi, B., Brake, C. A., Gruner, P., Badour, C. L., & Pittenger, C. (2018). The role of stress in the pathogenesis and maintenance of obsessive-compulsive disorder.   Chronic stress (Thousand Oaks, Calif.). Retrieved October 23, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841259/

Murayama, K., Nakao, T., Ohno, A., Tsuruta, S., Tomiyama, H., Hasuzawa, S., Mizobe, T., Kato, K., & Kanba, S. (2020, December 3). Impacts of stressful life events and traumatic experiences on onset of obsessive-compulsive disorder. Frontiers in psychiatry. Retrieved October 23, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744562/

Pinciotti, C. M., & Fisher, E. K. (2022, April 6). Perceived traumatic and stressful etiology of obsessive-compulsive disorder. Psychiatry Research Communications. Retrieved October 23, 2022, from https://www.sciencedirect.com/science/article/pii/S2772598722000253

U.S. Department of Health and Human Services. (n.d.). Obsessive-compulsive disorder. National Institute of Mental Health. Retrieved October 23, 2022, from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd 

Photo: Spratt, A. (2021, May 6). White and Brown Cat Print Textile Photo. Unsplash. Retrieved October 23, 2022, from https://unsplash.com/photos/4BwcmbExs5c 

Grief: An Inevitable Aspect of Life

Death is one of the few things in life that are guaranteed. At some point in time, every single one of us will lose a person or an animal who we love and care for so much. And with that loss, comes immense overwhelming feelings of sadness that are known as grief. Grief presents itself differently from person to person. Dealing with grief is a very individual experience dependent on many factors, including your personality, your coping skills, past life experiences, your faith, and how significant the loss was in your life (HelpGuide, 2022). Due to the individuality of grief, there is no set timeframe in which someone should be “healed” from it. I think it is fitting to put the word healed in quotation marks because, for many of us, the grief that comes from a loss of a loved one can last our whole lives.

Psychiatrist Elisabeth Kübler-Ross founded the concept of the “five stages of grief” in 1969 (HelpGuide, 2022). The stages are denial, anger, bargaining, depression, and acceptance. The first stage, denial, is characterized by feelings of disbelief and shock. Some common thoughts an individual can experience at this time are, “How could this happen to me?” and “It can’t be true” (Mind, 2019). Anger is the second stage, which includes blaming yourself or others for the loss and general hostile feelings and behaviors. “Why me?” or “Why them?” and “This isn’t fair” are some typical anger responses people have in this stage (Mind, 2019). Next comes the bargaining stage which is filled with guilt. Here, someone may have thoughts along the lines of, “Make this not happen, and in return, I will _____” (HelpGuide, 2022). The next stage, which is arguably the most commonly associated with grief, is depression. When one is in the depression stage, they experience feelings of hopelessness, intense sadness, and the sense that they are lost in life. “I’m too sad to do anything” is most likely a recurring thought that someone in this stage may face (HelpGuide, 2022). Finally, the last stage of grief, there is acceptance. Acceptance is about coming to terms with what happened: “Acceptance does not mean that somebody likes the situation or that it is right or fair, but rather it involves acknowledging the implications of the loss and the new circumstances, and being prepared to move forward in a new direction” (Mind, 2019).

It is important to note that not everyone experiences grief in these exact stages. Some people may go through the stages in a different order, skip some stages, or just not experience them at all. Even Kübler-Ross, who introduced this concept, acknowledges that healing from grief is not linear and that these stages are not one-size-fits-all. In her last book, about the stages of grief, she declares, “They were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss, as there is no typical loss. Our grieving is as individual as our lives” (HelpGuide, 2022). 

While grief is typically associated with the significant loss of a loved one, that is not the only instance from which grief can stem. A loss of any kind can provoke grief in someone. These losses include a divorce or a breakup, loss of a job, a miscarriage, diagnosis of an illness for you or a loved one, retirement, loss of a friendship, loss of safety after a trauma, changing careers, graduating, or even moving to a new place (HelpGuide, 2022). Regardless of the situation you are grieving from, it is immensely important to make sure you are taking care of yourself emotionally and physically during this tough time.

References

HelpGuide. (2022, October 13). Coping with Grief and Loss. Retrieved October 24, 2022, from https://www.helpguide.org/articles/grief/coping-with-grief-and-loss.htm 

Gautam, P. (n.d.). Unsplash. Retrieved from https://unsplash.com/@pgauti. 

Mind. (2019, July). Bereavement. Retrieved October 24, 2022, from https://www.mind.org.uk/information-support/guides-to-support-and-services/bereavement/experiences-of-grief/ 

Going Beyond the Baby Blues: Examining the Characteristics and Treatment of Perinatal Depression

Historically, it has been wrongfully believed that pregnancy and the puerperal period, also known as the postpartum period, serve as protective factors against mental health issues in women (Kerr, 2017). In recent years, this myth has been largely disproven as more women and mental health professionals are sharing their experiences and expertise on the matter of how pregnancy and the puerperal period are two areas of high concern where increased risk of developing mental health issues has been observed. One such critical mental health concern is perinatal, formally postpartum, depression which refers to the onset of depression or related symptoms beginning in pregnancy and/or following childbirth. The former term, postpartum depression, is limited to the period when the body is returning to its nonpregnant state, however it fails to acknowledge that depression during this time often begins during pregnancy (National Institute of Mental Health, 2022). Individuals with perinatal depression may experience extreme sadness, indifference, anxiety, and fatigue which makes it more difficult to care for oneself and the child (National Institute of Mental Health, 2022). 

Oftentimes, pregnancy and the time period following delivery can be a vulnerable and sensitive experience, as there is a multitude of changes occurring in one’s body to prepare for pregnancy and delivery. Physiological changes relating to the high and rapid variation in reproductive hormones, estrogen, and progesterone both during pregnancy and after delivery may lead to potential mood changes and emotional distress (Torres, 2020). Emotional stress may be heightened due to financial and social changes, such as the high expenses associated with keeping up with physician visits, medications, and postpartum care. Considering the range of potential triggers which may interfere with a new mother’s well-being, approximately 70% of women experience a short onset of emotional anguish following the delivery of their child (Torres, 2020). Colloquially referred to as the “baby blues”, this period of emotional stress is characterized by negative feelings of anxiety, sadness, or irritability, with the added responsibility of caring for a baby, sleep deprivation, and lifestyle changes. While “baby blues” may appear to be similar to perinatal depression, it is important to acknowledge that these are two very different conditions in their severity and duration. “Baby blues” are defined to be short-term and do not disrupt or impair an individual’s ability to carry out their daily activities. After a couple of days, patients will see an improvement in their mood without needing medication attention or treatment. However, perinatal depression is usually a longer-lasting condition paired with intense symptoms that can be emotionally and physically debilitating to an individual (Torres, 2020). 

Perinatal depression must be diagnosed by healthcare professionals, and although it is not a separate illness classification in the DSM-5 manual, patients must meet the provisions for a major depressive episode with the criteria of a peripartum-onset specifier (American Psychiatric Association, 2022). For a depressive episode to be classified as such, patients must experience at least five out of nine symptoms nearly every day for a two–week period: depressed mood, loss of interest or pleasure, change in appetite or weight, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue, worthlessness or guilt, reduced concentration or indecisiveness, or suicidal ideation or attempt (American Psychiatric Association, 2022). These symptoms may increase or decrease in severity throughout the depressive episode and may result in additional shame or guilt concerning motherhood. 

Evidently, perinatal depression can have dire consequences for the pregnant individual in question by hampering their quality of life. However, these consequences can also impact the baby’s well-being and sense of attachment and bonding with the mother. This can induce sleeping and feeding issues, which can introduce a host of new concerns for the child and mother (Van Niel & Payne, 2020). With the severity of perinatal depression, treatment is usually needed to resolve the depressive episode. Treatment options include cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and the use of medications such as antidepressants. CBT and IPT are two evidence-based psychotherapy approaches that revolve around improving one’s ability to challenge negative situations (National Institute of Mental Health, 2022). CBT is a more structured therapy approach in which an individual may work to identify and tackle harmful thought patterns, behaviors, and emotional responses by substituting them with realistic and positive ways of thinking about one’s challenges and situations (Cleveland Clinic, 2022). IPT allows one to better their communication and relationship skills to develop stronger support networks and realistic expectations and outlooks on their respective situations. This allows an individual to have more resources and control over their circumstances to deal with their issue (National Institute of Mental Health, 2022). Whether an individual chooses to use therapy, medications, or both, it is no doubt that these options should be available to any individual undergoing a pregnancy. While pregnancy is commonly viewed as a time to rejoice, we, as a society, need to acknowledge the social and biological difficulties that pregnancy may introduce to the individual. 

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text rev (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

Cleveland Clinic. (2022, August 4). Cognitive behavioral therapy (CBT). https://my.clevelandclinic.org/health/treatments/21208-cognitive-behavioral-therapy-cbt

Kerr, M. (2017, June 26). Perinatal depression. Healthline. https://www.healthline.com/health/depression/perinatal-depression#causes

National Institute of Mental Health. (2022). Perinatal depression. https://www.nimh.nih.gov/health/publications/perinatal-depression

Torres, F. (2020, October). What is Peripartum Depression (formerly Postpartum)? American Psychiatric Association. https://psychiatry.org/patients-families/peripartum-depression/what-is-peripartum-depression

Van Niel, M. S., & Payne, J. L. (2020). Perinatal depression: A review. Cleveland Clinic Journal of Medicine, 87(5), 273-277. https://doi.org/10.3949/ccjm.87a.19054

Impact of Sex and Gender on Mental Health

The prevalence of mental health disorders greatly varies between men and women. Mental health disorders are known to impact an individual's quality of life in terms of their emotions, behaviors, mood, and thought processes (Otten et al., 2021). Although mental illness can impact anyone, studies have shown that there are higher rates of specific disorders found in one sex compared to the other. In addition, it has been challenging for scientists to determine the true causes of the vast differences in prevalence rates between sexes.

The disorders that are more commonly identified in women are often related to the internalization of emotion while men are diagnosed with disorders that externalize emotions (Eaton et al., 2012). The National Comorbidity Survey has identified that women are approximately twice as likely to be diagnosed with anxiety disorder, social phobia, major depression, and panic disorder in comparison to men (Eaton et al., 2012). The survey has also indicated that men have higher prevalence rates for alcohol and drug dependence, as well as antisocial personality disorder when compared to women (Eaton et al., 2012). Moreover, dementia as well as mood and neurotic disorders are found more in women (Suanrueang et al., 2022). Intellectual disability, schizophrenia, along with mental and behavioral disorders are better detected in men (Suanrueang et al., 2022). In addition, each sex experiences different severities of the diagnoses. For instance, adverse symptoms related to schizophrenia are more commonly reported in men while there are worse anxiety symptoms present in women (Otten et al., 2021). Men have also reported having experienced more traumatic incidents in their lives, yet women are more likely to develop post-traumatic stress disorder after traumatic events (Otten et al., 2021). Additionally, suicide performed by men occurs more frequently while women have higher numbers of suicide attempts (Otten et al., 2021).

Although the origins of the prevalence rate differences between the two sexes have not been made clear, many factors that impact the rates have been determined (Otten et al., 2021). Seeing as sex refers to the biological construct of an individual at birth, factors including hormone production of sex-specific hormones may explain differences in relation to psychiatric and stress disorders (Otten et al., 2021). Gender refers to the self-identity of an individual and relates to the behavior associated norms and power distribution that society has assigned to men and women (Otten et al., 2021). Gender-related factors include; self-esteem, gender-related violence, and family-related factors (Otten et al., 2021). Socioeconomic positions and social interactions vastly differ among men and women depending on their culture, and where they live. Furthermore, disparities in education, family, and lifestyle-related factors are being studied as characteristics that impact differing mental health diagnoses in men and women (Otten et al., 2021).

All individuals regardless of sex and gender should be provided with fair mental health treatment options. The various differences in prevalence rates can change the future of mental health assistance. For instance, improved prevention options can be discussed with the respective sex (Suanrueang et al., 2022). Enhanced mental health evaluations can be performed and risk factors are more likely to be identified (Suanrueang et al., 2022). In addition, new medications can be formulated and more tailored treatment options can be provided. Ultimately, these unique prevalence rates can aid in the implementation of better mental health resources for men and women.

References

Eaton, N. R., Keyes, K. M., Krueger, R. F., Balsis, S., Skodol, A. E., Markon, K. E., Grant, B. F., & Hasin, D. S. (2012, February). An invariant dimensional liability model of gender differences in mental disorder prevalence: Evidence from a national sample. Journal of abnormal psychology. Retrieved October 4, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402021/

Otten, D., Tibubos, A. N., Schomerus, G., Brähler, E., Binder, H., Kruse, J., Ladwig, K.-H., Wild, P. S., Grabe, H. J., & Beutel, M. E. (2021, February 5). Similarities and differences of mental health in women and men: A systematic review of findings in three large German cohorts. Frontiers in public health. Retrieved October 4, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892592/

Suanrueang, P., Peltzer, K., Suen, M.-W., Lin, H.-F., & Er, T.-K. (2022). Trends and gender differences in mental disorders in hospitalized patients in Thailand. Inquiry: a journal of medical care organization, provision and financing. Retrieved October 4, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9019317/          

Photo: Nhân, D (n.d). People Wearing Sneakers. Pexels. https://www.pexels.com/photo/people-wearing-sneakers-1021145/

Caring for Our Caregivers: Physician Suicide Awareness and Prevention

The conclusion of September brings the end to National Suicide Awareness month, a topic often shunned by public discussion. Awareness regarding this issue should not be limited to just one month, rather year-round conversations are necessary to examine systemic issues and barriers regarding suicide prevention with additional emphasis on high-risk groups. Physicians are one such high-risk group who on average face a higher death-by-suicide rate than other professions, with studies estimating the suicide of 300-400 practicing physicians yearly (Yaghmour et al., 2017, p. 976). It is estimated that “The suicide rate among male physicians is 1.41 times higher than the general male population. And among female physicians, the relative risk is…2.27 times greater than the general female population” (American Foundation for Suicide Prevention, 2022). A fundamental problem exists that perpetuates the crisis seen in medical professionals. 

Not often viewed as the byproduct of an individual event, suicide is commonly the aggregated result of multiple risk factors, with the highest occurrence being mismanaged mental health conditions (American Foundation for Suicide Prevention, 2022). Following the completion of medical school, physicians enter a formative period of residency training for three to seven years to become specialized in their respective fields. Residency training is labor intensive and highly demanding of a physician's time, as individuals may work between 60-80 hours per week depending on their specialty and rotation by standardized working conditions. In 2003, The Accreditation Council for Graduate Medical Education (ACGME) imposed an 80-hour weekly work limit, averaged over four weeks, and 24-hour shift limit guidelines for residents (Accreditation Council for Graduate Medical Education, 2004). Though these regulations were created to combat overwork and sleep deprivation for residents, studies have shown it is a common occurrence to underreport or falsify one’s hours worked to comply with ACGME. Through an anonymous survey completed by 6202 residents at ACGME-accredited medical programs, “Nearly half of residents (42.9%) responded that they falsely reported their duty hours at some time, including 18.6% who reported falsely at least once or twice per month” (Drolet et al., 2013). Although legal limitations are established for resident working conditions, physician training generally applauds a visible dedication and commitment to maturing in one’s field. This may encourage residents to stay longer to observe more patients, take on more cases, and commit to more educational or academic tasks at home or in the hospital (on their own time). Thus, to fit national compliance, trainees might be more flexible in logging false hours. Long hours translate to fewer hours for oneself, whether it be doing leisure activities or spending time with loved ones.  

Amongst long hours and competitive, high-stress training environments, “... trainees often learn to ignore signs and symptoms of burnout, depression, and suicidality” (Kalmoe et al., 2019). A meta-analytic review of multiple studies examining suicide amongst physicians and healthcare workers found “... between 20.9% and 43.2% of trainees screened positive for depression or depressive symptoms during residency” (Mata et al., 2015). It is important to note that a significant increase in the onset of depressive symptoms lies at the start of residency, which supports the finding that training experience across all specialties is commonly distressing to the individual’s mental health  (Mata et al., 2015). In a study cohort of 740 first-year U.S. residents across 13 institutions and multiple specialties, it was examined that suicidal ideation escalated by 370% over the first several months of their training year (Guille et al., 2015). 

While physician training applauds fortitude and passivity from its residents, it is no doubt that the profession demands for its trainees to forgo themselves to be more devoted to their training. Though physicians routinely check for their patient's mental health concerns, medical culture routinely stigmatizes mental health treatment and support for its own. Lacking an adequate support network can further amplify the dehumanizing experience faced by medical trainees leading them to isolation in combating their mental health issues. Similar to the barriers faced by many others, resident physicians may also come across financial and social barriers in seeking mental health treatment. With medical educational debt having an average of $200,000-$300,000 and resident salaries being around $50,000-$60,000, residents may struggle to obtain affordable care or therapy combined with their other living expenses and continuing medical education. With finances not being a concern, even finding adequate time to schedule appointments may be difficult with the long shifts and on-call hours. 

While it is advised for physicians, particularly residents, to address their mental health conditions through treatment, it is vital to recognize this issue not as a personal conflict, but as a systemic crisis. Individual actions may fall short of the larger issue at hand, which is a large burden placed on physicians during their training to constantly be more and do more. It is crucial for medical training to become humanized to combat depressive symptoms faced by physicians and remind them they are not alone. 

References

Accreditation Council for Graduate Medical Education. (2004). The ACGME’s Approach to Limit Resident Duty Hours 12 Months After Implementation: A Summary of Achievements. ACGME Home. https://www.acgme.org/globalassets/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf

American Foundation for Suicide Prevention. (2022). Facts about Mental Health and Suicide Among Physicians. https://www.datocms-assets.com/12810/1578319045-physician-mental-health-suicide-one-pager.pdf

Drolet, B. C., Schwede, M., Bishop, K. D., & Fischer, S. A. (2013). Compliance and falsification of duty hours: Reports from residents and program directors. Journal of Graduate Medical Education, 5(3), 368-373. https://doi.org/10.4300/jgme-d-12-00375.1

Guille, C., Zhao, Z., Krystal, J., Nichols, B., Brady, K., & Sen, S. (2015). Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns: A Randomized Clinical Trial. JAMA psychiatry, 72(12), 1192–1198. https://doi.org/10.1001/jamapsychiatry.2015.1880

Kalmoe, M. C., Chapman, M. B., Gold, J. A., & Giedinghagen, A. M. (2019). Physician Suicide: A Call to Action. Missouri medicine, 116(3), 211–216.

Mata, D. A., Ramos, M. A., Bansal, N., Khan, R., Guille, C., Di Angelantonio, E., & Sen, S. (2015). Prevalence of depression and depressive symptoms among resident physicians. JAMA, 314(22), 2373. https://doi.org/10.1001/jama.2015.15845

Yaghmour, N. A., Brigham, T. P., Richter, T., Miller, R. S., Philibert, I., Baldwin, D. C., & Nasca, T. J. (2017). Causes of death of residents in ACGME-accredited programs 2000 through 2014. Academic Medicine, 92(7), 976-983. https://doi.org/10.1097/acm.0000000000001736