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December 6, 2016 / 6 Kislev, 5777

Posts Tagged ‘CBT’

The Tyranny Of OCD

Wednesday, May 5th, 2010

With Pesach behind us, what better time to take a closer look at the annual burst of intensity that propelled us, in the weeks and days leading to the yom tov, into a frenzy of cleaning?

That sustained embrace of scrupulous cleaning offers insight into a subject that has lately received a great deal of attention in psycho-educational literature. The topic, OCD, obsessive-compulsive disorder, might be understood by comparing it with that exhausting endeavor from which many of us are just starting to recover.

OCD is an anxiety disorder that strikes both children and adults. It is a form of “brainlock,” where distressing thoughts pop up in a person’s mind and refuse to be banished. The anxiety they generate compel the person to perform certain rituals meticulously, again and again, until they are done “right.”

OCD is often manifested by a preoccupation with arranging things in a very particular way; excessive cleaning or checking things ad infinitum; irrational fear of germs and contamination; asking the same question repeatedly when the answer is known; touching things a certain number of times; counting before executing the simplest action and many other rituals.

How does OCD differ from a normal drive for cleanliness and order in one’s life? To hark back to Pesach-cleaning, to insist on moving the stove and refrigerator to search for elusive crumbs would not qualify as “compulsive,” or “obsessive.” A once a year endeavor, this effort is inspired by an uplifting sense of purpose. But imagine a housewife who, in a quest for absolute spotlessness to allay OCD anxiety, is driven to similar exhausting measures every single day?

Such is the terrible burden of OCD, whose rituals are usually hated and dreaded by the sufferer due to their utter meaninglessness and consuming nature, yet impossible to set aside.

The disorder is far more disabling than people realize and consumes untold hours and outputs of energy. Unlike ordinary worries and obligations OCD obsessions and compulsions do not go away even when the demanding rituals are faithfully carried out.

In fact, these actions tend to increasingly dominate a person’s life. They take inordinate amounts of time, may interfere with a person’s daily schedule and cause significant distress.

Observing a person engaged in the rituals of OCD behavior would be enough for most people to regard him as unstable. OCD sufferers know this – fearful of being shunned as crazy, people suffering from OCD go to great lengths to hide their symptoms.

In children especially, the fear of being ridiculed or regarded as weird exacts a terrible price in self-esteem and the need to maintain secrecy.

Because OCD compulsions and obsessions gradually increase and encroach further on a person’s daily routine, life for the victim can become unbearable.

The rituals of repeatedly washing off invisible dirt, for example, or counting a certain number of times before entering or leaving a room, or tying one’s shoes six or eight times until they feel “right,’ begins to get more involved and consume even greater amounts of time.

Psychologists explain that trying to suppress the compulsions and obsessive thinking by sheer will power doesn’t work. It produces so much anxiety that the person surrenders to the urge or becomes haunted by other obsessions.

OCD Behavior In Children And Adolescents

Recognizing the symptoms of obsessive-compulsive disorder may be challenging, as the symptoms can easily be misinterpreted as willful disregard, oppositional behavior or immaturity.

Often, a parent or teacher only sees the result of the symptom such as hours in the bathroom; extended dallying in the bedroom; inability to finish assignments or tantrums when the child cannot do something his or her way and is overwhelmed with anxiety.

If left untreated, peer relationships, functioning in school and with family all may suffer, cautions Dr. Edna Foa, author of Stop Obsessing!

OCD is usually not outgrown. If left untreated, it follows its victims into adulthood, as the following excerpt from a personal memoir illustrates.

The Monster And Me

In, The Monster And Me, Rena Galloway remembers starting to line up her toys when she was five. At eight she was lining up her shoes several times a day, as well as the books in her school bag and the items in the medicine closet. At nine, after her parents divorced, her compulsions spread to the pantry. She lined up cans of food in alphabetical order, with all the labels facing in one direction.

“What are you doing in the pantry so late?” my mother called from her bedroom, making my hand jerk in fear.

“Just looking for something for lunch,” I managed.

“At this hour? But I made your lunch already, you saw me make it.”

“I know. I just wondered if there were any raisins left. I’m in the mood for raisins.”

“Enough of this nonsense! Go straight to bed!”

She thought I was being impudent. I was exhausted and longed to go to sleep.. I couldn’t allow myself to go to bed until I had completed arranging the pantry shelves. If I didn’t, I’d lie awake for hours, fearful of something bad happening to my family. I waited in bed for a half hour until I was certain she was sleeping and then crept into the pantry and finished arranging the cans. Only then did I finally go to sleep. This happened three or four nights a week over many months.

OCD At Home

Symptoms of obsessive-compulsive disorder at home are often more intrusive than school. Life for the child and family can become stressful and all family members may feel powerless to change rigid patterns of behavior.

At home, children with OCD may display a combination of the symptoms listed below.

Repeated obsessive thoughts. Unlike ordinary worries, these obsessions (such as fear of becoming fatally ill) are not generally realistic. Often the child may deny these behaviors or be embarrassed by them.

Repeated actions to prevent a feared consequence – such as repeating certain words, tapping objects or counting to certain numbers to ward off danger to oneself or to a family member.

Consuming obsessions and compulsions. The child or adolescent is continually preoccupied with these fears (for example, he avoids nearly all contact with objects due to fear of contamination or washes hands for hours).

Extreme distress if others interrupt a ritual. Children may have extended tantrums if a parent insists that the ritual be discontinued.

Difficulty explaining unusual behavior. Children with OCD may not be able to explain what their worries are or why they feel compelled to repeat their behaviors.

Attempts to hide obsessions or compulsions. Children and adolescents are often ashamed of their worries or strange habits and will make great efforts to keep their thoughts or rituals a secret.

Concern that they are “crazy” because of their thoughts. Children with OCD may recognize that they think differently than others their age. Consequently, these children have low self-esteem.

At School

The differences in behaviors seen at home and school can be significant. At school, students may be successful in suppressing symptoms, while they may be unable to at home. Families often seek treatment once symptoms affect school performance.

At school, a child with OCD may exhibit one or more of the following symptoms:

Difficulty concentrating, which may affect his ability to follow directions, complete assignments and pay attention. Concentration can be derailed by repetitive thoughts that come of their own volition. Finishing work in the appropriate time can be difficult and starting schoolwork can be difficult, too.

Perfectionism. A child with OCD may have impossibly high standards of perfection; may spend most of his time erasing and starting over. The child may be almost paralyzed by the inability to tolerate his results that are less than perfect.

Social isolation or withdrawal from interactions with peers due to bizarre habits

Low self-esteem manifesting in social and academic activities

Problem behaviors, such as arguments, resulting from misunderstandings, teasing regarding the child’s behavior, or because the child often cannot let go of an argument.

What Causes OCD?

OCD was long assumed to be purely psychological, the mind’s reaction to overly strict parents or abnormal emphasis on cleanliness. Scientists now believe it is the result of a chemical imbalance in the brain.

“OCD tends to occur in families, meaning there is a genetic component. However, scientists believe that it takes a stressful event for the condition to activate, and exposure to various scenes or stories can aggravate it, said Dr. Swedo, in Science News.

OCD is the mind’s way of trying to impose control in one’s life when events feel out of control, she said.

Research has shown that OCD is triggered by the way the mind handles messages about fear and doubt.

Cognitive Behavioral Treatment – What’s Involved?

CBT is recommended for children and adolescents with obsessive-compulsive disorder. In CBT, a young person is helped to identify obsessive thoughts and compulsions and what triggers them.

With younger patients, personifying the obsessions (for example, “Germy” to describe the fear of germs) allows children to “fight back” against the thoughts or behaviors that create barriers between themselves and peers or family members.

CBT focuses on changing behaviors by “exposure” and “response prevention.” “Exposure” works by having the patient, under the therapist’s guidance, confront the obsession without resorting to the ritual that is meant to allay anxiety. The patient refrains as long as possible from surrendering to the compulsive urge, weathering the panic and anxiety the delay causes.

For example a ten-year old girl named Miriam could not fall asleep at night without calling out “Good night, Mommy!” two, four, six or eight times. Sometimes, she would have to add, “Sleep well!” an equal number of times. If her mother refused to respond, she couldn’t fall asleep.

Miraim’s therapist helped her break these compulsions first by getting her to talk and even joke about them. They rehearsed the nighttime calls and talked about what would happen if she kept them down to first four, then two a night, and then one.

Slowly, Miriam was able to practice “response prevention,” reducing the calls without feeling unbearable anxiety.

One night she fell asleep without a single extra “Good night, Mommy!”

Individual psychotherapy may be useful for young people with OCD, particularly when they have ongoing stressors in their lives that make symptoms worse. Children with obsessive-compulsive disorder often carry a sense of failure, as if the illness was their fault. In many cases, they know that their disturbing thoughts and rituals are generated by their own mind which can increase their self-blame and shame. Individual psychotherapy can help young people become aware of and address these feelings.

Parent guidance sessions can help parents manage their child’s illness, identify effective parenting skills, and learn how to function better as a family despite the disorder. Family therapy may be beneficial when issues are affecting the family as a whole.

“OCD is like a greedy tyrant,” says Dr. Taussig. “The more you surrender to it, the more it takes over your life. But once you expose the obsessions for what they are, you drain them of power.” She has posted a plaque on one of the walls of her office that encapsulates her approach to this daunting anxiety disorder:

Know your enemy

For once he’s known

He’s nothing but a humbug

A tyrant dethroned.

An acclaimed educator and education consultant, Mrs. Rifka Schonfeld has served the Jewish community for close to thirty years. She founded and directs the widely acclaimed educational program, SOS, servicing all grade levels in secular as well as Hebrew studies. A kriah and reading specialist, she has given dynamic workshops and has set up reading labs in many schools. In addition, she offers evaluations, social skills training and shidduch coaching, focusing on building self-esteem and self-awareness. She can be reached at 718-382-5437 or at rifkaschonfeld@verizon.net

Rifka Schonfeld

Strep Throat And Anxiety: Is There A Connection?

Wednesday, May 13th, 2009

Rachel is a bubbly and adorable 8-year-old girl. From a young age, she was afraid of the dark, but after a minimal amount of coaxing, would eventually go to bed. Outside of the home, Rachel loved school, excelled in her classes, and looked forward to going to school each day. Suddenly, one night, all of this changed. Rachel would not go to bed. She claimed she was afraid of the dark. After four hours of her mother sitting beside her bed, Rachel finally fell asleep; however, she awoke an hour later screaming, “Please don’t leave me alone. I can’t be alone.” Rachel’s mother, in an effort to calm her down, spent the night on the floor beside the bed. Even so, Rachel woke about every half-hour to check that her mother was still there.

The next morning, Rachel refused to go to school and screamed, “I am afraid and I can’t leave you, Mommy.” Her mother was confused by this behavior but reluctantly brought her to school even as Rachel kicked and screamed. At school, she continued to cry all day and even fell asleep a few times. At bedtime that night, the same scenario replayed itself. At this point, Rachel’s mother knew that there was something wrong with her daughter, but she could not figure out what the problem was. Rachel seemed fine: she had no fever, no rashes, no pain that she complained of in her ears or throat.

When this strange, fearful behavior went on for a few weeks, her parents took Rachel to the pediatrician for advice. Their pediatrician examined Rachel and could not find physical symptoms, so she sent them to a psychiatrist. While the psychiatrist gave Rachel medication that somewhat eased the behavior, her mother noticed that her daughter was still not the same Rachel. Bedtime and leaving to school were still rather difficult. Her mother spent many hours on the Internet trying to figure out what was wrong with her once happy and lovable daughter. She discovered information about a syndrome called PANDAS that she believed was the cause of Rachel’s anxiety and fear.

In 1998, Dr.Susan Swedo, from the Pediatric Developmental and Neuropsychiatry branch of the National Institute of Mental Health, found a connection between strep throat and anxiety, obsessive-compulsive behavior and tics. This syndrome is called PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). PANDAS often occurs when a child who has not yet reached puberty has strep throat that goes untreated or unnoticed. In every bacterial infection, the body produces antibodies to fight against the invading bacteria, and eliminate them from the body. In the case of PANDAS, the strep reacts with a part of the brain called the basal ganglia, which causes the child to act as if s/he is suffering from a mental illness. For example, a child, like Rachel, who is slightly anxious wakes up one day and is extremely anxious and has a hard time functioning. Or in other instances, a child may suddenly begin to chew on his or her collar or twirl her hair obsessively. Similar to Rachel’s mother, parents are usually able to pinpoint a certain day when their child began to exhibit these extreme symptoms.

If you feel your child’s behavior has suddenly changed and suspect that he or she has PANDAS, it is important to see a pediatrician and have a throat culture and a blood test done. Take into account, there are times that the culture may come back negative but the antibody levels in the blood may be very high. If the levels are high, the child needs to be put on antibiotics. Studies have shown that PANDAS responds to an antibiotic called Zithromax. There are various ways in which this antibiotic is used to treat the PANDAS. This needs to be discussed and administered by your pediatrician.

Once it is confirmed that it is PANDAS and the child is on antibiotics, the child should be taken for some cognitive behavioral therapy (CBT) to help eliminate the negative symptoms that have become ingrained in his or her everyday routines. CBT means that with the help of a therapist the child can teach her brain to think and act in a different way than it operated in the past. CBT is based on the idea that our thoughts cause feelings and behaviors. The benefit is that if the child can change her thoughts, she can change her behavior. While the antibiotics help to erase the exaggeration of symptoms, CBT helps to eliminate all fears, tics, behaviors and anxieties.

When Rachel’s mother read about PANDAS, she believed that her daughter was suffering from the syndrome. She was a bit confused, though, as Rachel had no strep symptoms. Regardless, she took her to the pediatrician who took a strep culture. While it came back negative her antibody levels were very high. The doctor put Rachel was put on a course of Zithromax, and with the consent of the psychiatrist weaned her off the psychiatric medication, and she then came to see me for CBT. We worked together on ways to help her conquer her anxieties and together with the antibiotics in a matter of weeks, Rachel once again became the sweet lovable girl who loved school and could sleep in her own room by herself.

Another client I worked with was an 11-year-old boy named Josh. Josh had been very social and was a straight-A student. Like Rachel, he, too, suddenly developed some rather strange behaviors. He would constantly smell his hands and explained to his father, “I think they smell. I keep checking to see if they smell.” He also acquired a tic in which he was constantly rubbing his eye and shrugging his shoulders. With this tic, Josh would also constantly bite on his shirtsleeve. Aside from his strange tics, Josh’s grades in school began to drop and his friends stayed away from him.

Josh’s parents were confused by this abrupt change in their once friendly and clever son. Eventually, they took him to the pediatrician who thought that they should test for PANDAS. While Josh had no strep symptoms, his culture came back positive and his antibody levels were very high. The pediatrician put him on a regimen of Zithromax and sent him to me for some CBT. After several months, with the help of CBT Josh was able to control the thoughts and actions that seemed to overtake him. Miraculously his tics and shirt biting all disappeared. Josh started to do well in school again and his friends began spending time with him again. His mother once told me that she feels that with the identification of PANDAS and work with CBT “a cloud has lifted from her son.”

Only recently has PANDAS become more acknowledged by pediatricians. Even today, it is still not completely understood or accepted by the medical community. Regardless, PANDAS and its devastating effects is afflicting many of the children in our community. Strep is spread easily in our highly populated schools and large families making us more susceptible to PANDAS. Those who have been treated have been able to see tremendous improvement from antibiotics and CBT. It is important for all parents to educate themselves on this topic and if they suspect their child might have PANDAS, they need to have them tested and arrange for therapy. As Rachel and Josh’s parents can attest, PANDAS is a frightening thing to watch happen to a child, however, we can all take comfort in the support available and the real possibility for recovery.

*Names and some details have been changed to protect the client’s identity.

Michal Geffner is a LMSW psychotherapist practicing in the Flatbush area sharing office space with Vicky Harari. She specializes in anxiety disorders in children and adults and has a broad spectrum of training and experience in all fields. Michal Geffner may be contacted at (718) 692-2289 ext. 2; or by e-mail at michalgeffner@gmail.com.

Michal Geffner

Printed from: http://www.jewishpress.com/sections/family/parenting-our-children/strep-throat-and-anxiety-is-there-a-connection/2009/05/13/

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