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Depression in Men: Why is it Different?

Social, Psychological, and Diagnostic Aspects of Depression in Men

Four times more men die by suicide than women, and yet half as many men are diagnosed with depression as are women (1). In researching this topic, I was encouraged by the shift our society is making towards understanding depression in men and the factors that push them to such lengths. However, there is clearly still a long way to go. A book I skimmed early on in my search, aptly titled Men and Depression, by Sam Cochrin and Frederic Rabinowitz, mentions in the introduction that “A book that examines distress and depression in men may be seen by some as politically provocative.” In 2000, when that book was published, many researchers and clinicians were working to move public perception of mental disorders in men inch by inch. They recognized that the disparity between the number of men diagnosed with depression and the number of men who kill themselves indicates a hidden population of men who battle their depression in secret. 21 years later, the number of articles under a “depression in men” search in Google Scholar numbers over 3.5 million.

As a woman who suffers from depression, I feel relatively safe in disclosing my diagnosis. People are generally sympathetic and understanding when I discuss my symptoms. But how do men feel about the way their depression is received? A man I know has been dealing with depression for a long time, so I asked him exactly that question. Thankfully, he told me that his social circles have been largely supportive, which I think is an encouraging sign for our culture’s direction. But what factors make the rates of suicide between men and women so different? If we’ve come from “politically provocative” to millions of research articles in two decades, why are many men still suffering in silence? I want to dig into this issue to understand the historical trends, what sometimes makes depression in men different, and what we can do to keep the conversation going.

Historical Epidemiology of Suicide

In a really deep dive, we could go way back to Hippocrates and Galen to explore the perceived gender divide on mental disorders, which would be interesting. But in this context, we’ll stick to the 20th and 21st centuries. Let’s take a look at this set of data from the CDC’s Data Finder (12). It’s compiled mostly by decade between 1950 and 2015. This graph of the data, which I made with my rusty skills in Excel, illustrates the suicide trends by rate among men in various age groups.

Although the rate of suicide among all ages has remained relatively stable, trends within age groups are concerning. Suicides among 15-24 year-olds have increased dramatically, as have those among 25-44 year-olds. Despite a somewhat steady decline in the suicide rate of men aged 65 and older, they remain the group with the highest rate. By 2019, the rate of suicide in men had increased from 21.1 deaths per 100,000 to 23 deaths per 100,000 (13). For every 100,000 men, 23 deaths doesn’t immediately sound shocking. But to illustrate the numbers in a different way, consider that in 2019, a horrifying total of 37,256 men killed themselves in the U.S.

It introduces another layer of complexity to compare the data on men to the data on women. The suicide rate among women of all ages has increased since the 50’s more than it has among men, but it still sits markedly lower. In 2019, the overall suicide rate among women was 6.2 deaths per 100,000 people (13). Compared to 37,256 male suicides, the country saw 10,255 female suicides. Both of those numbers are unimaginable to me, but it’s worth investigating; why is the rate for men so much higher than it is for women?

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Photo by Mykyta Martynenko on Unsplash

Diagnostic Factors

The wildly higher rate of suicides among men than in women, combined with the average 2:1 ratio of depression diagnoses in women versus men, convincingly suggests that depression in men is going undiagnosed. An increasingly accepted hypothesis regarding this conclusion is that depression in men and women can be experienced in different ways (10). The current diagnostic tools don’t capture all of the symptoms of depression that men commonly face. The gender differences in symptomatology have led some to argue for the recognition of separate depression diagnoses for men and women. Magovcevic and Addis conceptualized the differences as constituting typical depression plus a subtype, masculine depression (6). Subsequent research shows that some men who don’t fully fit the diagnostic criteria on traditional depression questionnaires may be diagnosed when masculine depression symptoms are considered.

Masculine Depression Symptoms

“Masculine depression” (also called male depression and a variety of other terms), is characterized by more symptoms of anger, aggression, risk taking, and substance abuse than tend to occur in women. These symptoms are examples of “externalizing features.” They serve to express a person’s emotions in an outward, active way. “Internalizing features” of depression are identified by retreating into one’s self, such as by ruminating, engaging in negative self-talk, and isolating from others.

New Self-Report Scales

To investigate the efficacy of adjusted self-report scales at identifying depression in men, researchers created the Gender Inclusive Depression Scale (GIDS) using two other male depression scales validated with small cohorts. When symptoms of masculine depression – the externalizing features – are included in a traditional diagnostic survey, the rates of depression diagnoses among men and women are not significantly different (7). In other words, the gender differences disappear. Another scale, the Male Depression Risk Scale (8), measures emotion suppression, drug use, alcohol use, anger and aggression, somatic symptoms, and risk-taking. The sensitivity of the MDRS is similar to that of the PHQ-9 in recent suicide attempt identification (9).

Why is Depression in Men Sometimes Different?

To be clear, it’s a continuum; many men are diagnosed with depression using traditional questionnaires. But for the ones who aren’t, the answer is probably based in gender norms. Men who have depression and who identify with traditional ideals of masculinity are more likely to experience masculine depression symptoms (4). In a society that has traditionally viewed men who express sadness as “weak” or “feminine,” it makes sense that sometimes, depression in men is displayed as anger or in attempts to cope with it through substances. Sadly, it’s more socially acceptable for men to express anger than sadness, self-doubt, or anxiety.

Photo by Jordan McQueen on Unsplash

Why is the Suicide Rate Among Men so Much Higher?

If newer diagnostic scales indicate that the rates of depression in men and women are actually more alike than previously thought, what is going on with the suicide rates? Why would men die by suicide four times more often than women? It’s hard to know how many suicides could have been prevented by mental health intervention, but it’s logical to think that men who aren’t seeking counseling or who are dismissed without a diagnosis would be more likely to turn to suicide as the answer. Additionally, we know that although men complete suicide more often than women, women attempt it more often (11). Men tend to use more lethal methods, and for some men, the act of suicide represents an affirmation of strength and independence (2). It is crucial that we improve identification and treatment of depression in men (5).

A Note on “Masculine” and “Feminine”

With all of this discussion about a “masculine” depression facet, I have a small fear that readers of this post will leave feeling as though their diagnosis of depression must have been of the feminine kind. It’s not. It’s just depression – men, women, nonbinary people – it doesn’t impose judgement on your identity, it simply is. Just as men may experience more anger and impulsivity as part of their depression, women may be more likely to suffer body image issues and self-harm behaviors. But it’s a bell curve; just because men are more likely than women to exhibit anger as a sign of depression doesn’t mean that women can’t as well. Statistically, neither gender is more closely associated than the other is with the typical symptoms (8). The only gendered difference exists in the subset of “masculine” symptoms. The core set of symptoms that are covered in typical scales like the PHQ-9 remain the main diagnostic components of what we know depression to be. Expanding the criteria by creating a subset of symptoms more associated with men is just a way of widening the net in order to keep people from falling through the cracks.

For more reading on how men can view depression, suicide, and masculinity, check out this article. The author provides evidence for a variety of views that men hold about how mental health and suicide relate to masculinity.

Identifying Depression in Men Going Forward

For a long time, our definition of depression was too narrow. The research on gender differences in depression, which I have only barely scratched the surface of, is vast and still growing. Although the standard depression questionnaires remain focused on internalizing features to the exclusion of the externalizing ones, authorities on the matter have acknowledged the issue in other ways. The American Psychiatric Association has a webpage from 2005 that describes the early research and what to watch out for in men who may have depression. They now have a number of web pages, magazine articles, fact sheets, and books about men and depression. Someday, I hope that standard depression questionnaires will include measures for symptoms that men exhibit, but until then, we can continue to reduce stigma and spread the word about how depression in men can manifest.

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Photo by Marco Bianchetti on Unsplash

You can pass online resources on to the men you know. You can talk about it with your doctor. You can listen to your friends, fathers, brothers, and sons. Assure them that having feelings doesn’t make them less of a man, it just makes them human.

Resources

  • National Suicide Prevention Lifeline: 1-800-273-TALK (1-800-273-8255)
  • Advice on looking out for friends: beyondblue.org
  • Potential symptoms and tips for self-care: texashealth.org
  • Information, resources, and community: headsupguys.org

Citations

  1. “By the Numbers: Men and Depression,” December 2015. https://www.apa.org/monitor/2015/12/numbers.
  2. Canetto, Sylvia Sara, and Anne Cleary. “Men, Masculinities and Suicidal Behaviour.” Social Science & Medicine 74, no. 4 (February 2012): 461–65.
  3. Cochran, Sam, V, and Frederic Rabinowitz E. Men and Depression: Clinical and Empirical Perspectives. Academic Press, 2000.
  4. Genuchi, Matthew. “Anger and Hostility as Primary Externalizing Features of Depression in College Men.” Psychological Sciences Faculty Publications and Presentations, August 1, 2015. https://scholarworks.boisestate.edu/cgi/viewcontent.cgi?article=1223&context=psych_facpubs.
  5. Keohane, Aisling, and Noel Richardson. “Negotiating Gender Norms to Support Men in Psychological Distress.” American Journal of Men’s Health, October 11, 2017. https://pubmed.ncbi.nlm.nih.gov/29019282/.
  6. Magovcevic, Mariola, and Michael Addis. “The Masculine Depression Scale: Development and Psychometric Evaluation.” APA PsycNet, 2008. https://psycnet.apa.org/record/2008-09203-001.
  7. Martin, Lisa, A, Harold Neighbors W, and Derek Griffith M. “The Experience of Symptoms of Depression in Men vs Women: Analysis of the National Comorbidity Survey Replication.” JAMA Psychiatry, October 2013. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1733742.
  8. Rice, Simon, M, and Anne-Maria Moller-Leimkuhler. “Development and Preliminary Validation of the Male Depression Risk Scale: Furthering the Assessment of Depression in Men” 151, no. 3 (December 2013): 950–58.
  9. Rice, Simon, M, John Ogrodniczuk S, David Kealy, and Zac Seidler E. “Validity of the Male Depression Risk Scale in a Representative Canadian Sample: Sensitivity and Specificity in Identifying Men with Recent Suicide Attempt.” Journal of Mental Health, November 2017, 132–40.
  10. Rutz, Wolfgang, Jan Walinder, and Lars Von Knorring. “Prevention of Depression and Suicide by Education and Medication: Impact on Male Suicidality.” International Journal of Psychiatry in Clinical Practice, January 8, 1997. https://www.tandfonline.com/doi/abs/10.3109/13651509709069204.
  11. Schumacher, Helene. “Why More Men than Women Die by Suicide.” BBC Future (blog), March 17, 2019. https://www.bbc.com/future/article/20190313-why-more-men-kill-themselves-than-women.
  12. “Table 30. Death Rates for Suicide, by Sex, Race, Hispanic Origin, and Age: United States, Selected Years 1950-2015.” CDC, 2017. https://www.cdc.gov/nchs/data/hus/2017/030.pdf.
  13. “Underlying Cause of Death, 1999-2019 Request.” Data Table. CDC WONDER. Accessed January 17, 2021. https://wonder.cdc.gov/controller/datarequest/D76.

Science Saturday: Depression and the Immune System

Did you know that immune changes are associated with Major Depressive Disorder? I certainly didn’t.

Lately, I’ve been fascinated by the research on depression and the immune system. Perhaps you’re more in-the-know about this topic than I am and this doesn’t surprise you, but I was shocked to learn that not only do there appear to be measurable changes to the immune system with Major Depressive Disorder, but there are numerous studies on it dating back decades. This isn’t a fringe area of research! Let’s take a look at what changes there are and what they mean for people with depression.

The Evidence: T Cells and Depression

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bodytomy.com

T cells are a kind of lymphocyte, which are themselves a type of leukocyte, or white blood cell. Lymphocytes are involved in what’s called adaptive immunity; they use molecules on other cells – the body’s and invading pathogens – to recognize foreign material and defend against it. Kinds of lymphocytes include T cells, B cells, and Natural Killer cells. Different types of T cells perform different roles, such as “helper” cells (Th- cells), “regulatory” cells (Treg cells), and cytotoxic cells. CD4 and CD8 (which refer to markers on the cell surface) are the two main categories of T cells. CD4 T cells are mainly helper cells, and CD8 T cells are mainly cytotoxic, meaning they mount direct attacks against invaders.

Both main types of T cells, CD4 and CD8, have other molecules attached to their surfaces. Some are receptors that grant the cell access to infections; two such receptors are known as CXCR3 and CCR6. Antidepressant-free patients with MDD have been shown to have significantly lower expression of both receptors on both types of T cells. The same study also found a significant trend in MDD towards fewer Natural Killer cells, a finding that was corroborated in another study.

Research has shown that T cells have a neuroprotective quality. T cells migrating to the brain can reduce stress, promote neurogenesis (growth and development of nervous tissue), and reduce inflammation. Study after study have found inflammation, changes in immune cell composition, receptor alterations, and gene expression changes associated with Major Depressive Disorder.

Causes and Effects of MDD Immune Changes

All of these changes are fascinating in themselves, but are they the results of depression, causes of it, or some intermediary factor?

The Sickness Behavior Hypothesis

Some researchers view depression as a maladaptive result of what’s called “sickness behavior”. Sickness behavior is a vertebrate trait that, through behaviors like somnolence, anhedonia (loss of interest or pleasure), and reduced or no eating, conserve energy that can be directed towards fighting infection. Researchers have presented evidence that both sickness behavior and depression are mediated by pro-inflammatory cytokines– proteins that act in cell signaling roles. These two observations- depression and sickness behavior share symptoms as well as mediators- led to the following hypothesis. Depression is the alternate, maladaptive pathway of molecular processes that, on the other pathway, lead to sickness behavior. Under this hypothesis, the depression pathway leads to neurodegenerative changes that make repeated episodes more likely. Adding that to other research that shows a link between sickness behavior and major depression, and a fascinating picture emerges.

Sickness behavior and major depression do look remarkably alike in their symptoms, and we do know that major depression is often a lifelong illness.

Approximately 60% of people with MDD who experience a single depressive episode go on to have a second episode, and about 70% are likely to experience a third episode. Similarly, having had three episodes increases the chances to about 90% that a fourth episode will occur.

Functional Consequences

Biochemically, these changes are significant. Functionally, do they affect the people who have them? The answer may be yes. One study found a 59% increase in the risk of infection following one depressive episode. The increases weren’t linear, but the risk did go up again after the fourth episode. In addition, among college students, poor mental health is correlated with acute infectious illness.

Fortunately, treatment with antidepressants, if effective for depression, also returns T cell subsets to normal ratios. Differences in the subset ratios between those who responded to treatment and those who didn’t may help determine the chances of efficacy for a particular patient with antidepressant treatment.

 

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Science Saturday: Sensory Processing Disorder

Today’s topic is Sensory Processing Disorder. I didn’t have a specific question to answer, so I decided to make this post an overview of our current understanding of SPD. I’m particularly interested in this topic because I have Sensory Processing Disorder. I was diagnosed young and have had two rounds of occupational therapy, each several years apart. My knowledge of SPD centered around my own experience of it and what I’ve been taught in occupational therapy, so I was eager to dive into the literature and learn more.

Sensory Processing Disorder as a Diagnosis

SPD was first described as a construct by Ayres in 1964. At that time, it was known as Sensory Integration Dysfunction. Now, SPD has several subtypes, including Sensory Modulation Disorder.

Sensory Modulation Disorder

Three main categories compose SMD: sensory over-responsivity, under-responsivity, and sensory seeking.

Sensory Over-Responsivity (SOR) can be defined as:

…exaggerated responses to one or more types of sensory stimuli not perceived as threatening, harmful, or noxious by children and adults who are typically developing.

Analysis by different authors of data from a 2004 study that investigated the prevalence of SPD among kindergarten children in a Colorado school district found the prevalence of sensory over-responsivity to be between 2.8 and 6.4%.

Experiencing Sensory Under-Responsivity (SUR) might look like:

…quiet and passive, appearing to disregard stimulation by not responding…[they may have] inadequate body awareness, poor endurance, and movements that are not appropriately graded.

And lastly, sensory seeking, or Sensory Craving (SC), is “…craving sensory stimulation and appearing to be obsessed with obtaining additional sensory input.”

Sensory-Based Motor Disorder and Sensory Discrimination Disorder

The other two subtypes of SPD are Sensory-Based Motor Disorder, which includes dyspraxia and postural disorder, and Sensory Discrimination Disorder, which can affect one or more sensory systems. A diagnosis of Sensory Processing Disorder can include symptoms in each of the subtypes; in fact, it’s often a mishmash of seemingly contradictory symptoms that fit into different types.

SPD and its subtypes are included in the 2005 version of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3R). However, it’s not included as its own disorder in the Diagnostic and Statistical Manual 5 (DSM-V), largely because of lack of research and no official consensus on its definition. Sensory symptoms are described in association with Autism Spectrum Disorder and ADHD, but SPD has remained a controversial diagnosis in some circles. Unfortunately, this could be preventing families and adults from getting help for their symptoms.

Neurological and Physiological Research

Fortunately, there is evidence supporting SPD as a valid diagnosis, which could lead to changes down the road. A 2013 study compared the brains of boys with and without SPD (sample size of 40) using diffusion tensor imaging. Significant differences in white matter microstructure were found in the posterior corpus callosum, corona radiata, and thalamic regions. This study used the cardiac vagal tone index to measure the physiologic reactivity of 15 children. The results were significant and showed that the kids with SPD had less effective vagal tone than kids without SPD. This indicates that people with Sensory Processing Disorder may have impaired parasympathetic functioning. I have no reason to doubt this result, I just wish the sample size were larger.

Not Significant?

I wanted to include this study, and as I read through it, I reached the part where they break it to you that the results were not statistically significant. Darn! (Remember when I said I was biased?) In any case, it’s still interesting, and this is part of what science is about; you can still learn something from insignificant results.

An EEG study with a sample size of 53 tested kids’ brain waves by introducing a “conditioning” stimulus followed by a “test” stimulus. The idea is that your brain becomes accustomed to stimuli that it deems safe, so the test stimulus elicits a smaller reaction than the conditioning stimulus. This is called sensory gating. As a group, the kids with sensory processing disorder showed less sensory gating than the comparison group (p= 0.04), but it wasn’t statistically significant when an adjusted alpha level was used. If the results are robust enough, it indicates that people with SPD don’t get conditioned by stimuli like people without SPD. Every instance of a startling stimulus produces the same reaction as the first one did.

Sensory Processing Disorder and Autism

The vast majority of people with Autism Spectrum Disorder (ASD) also have sensory challenges. Yet, not everyone with SPD also has ASD. Research is beginning to tease apart where the overlaps lie. Using the same imaging technique as in the study above, researchers found differences between the white matter in boys with autism and the white matter in boys with SPD alone. Compared to a control, both groups’ white matter differences overlapped in tracts thought to contribute to sensory processing. However, the boys with ASD had additional white matter differences in tracts linked to social processing. Other research suggests that assessing cognitive styles may be a good way to differentiate between Sensory Processing Disorder and Autism Spectrum Disorder.

Sensory Processing Disorder and Mental Health

If you’ve been keeping up with my blog (if not, welcome), you know that I have sensory processing disorder and depression. I stumbled upon a couple of studies that show correlations between sensory dysfunction and mental disorders. This one, for example, shows that both under-responsiveness and over-responsiveness correlate with depression and impulsivity. Another one suggests that under and over-responsiveness may be “trait” markers for people with major affective disorders. That last one seems like a stretch to me, but my own perception of those studies is that a.) perhaps there’s some neurological connection between the white matter changes of SPD and mental illnesses, and/or b.) it’s tough to live with SPD, leading many with the disorder to develop secondary disorders.

This is a complex topic, and I’d love to hear your thoughts. Let me know what you think in the comments.

Science Saturday: How Does Nature Affect Mental Health?

I’m hoping to make this the first post in a series called “Science Saturdays” (now taking suggestions for a more creative name) where I dive into the research at the intersection of mental health and (fill in the blank). I dipped my toes into these waters with previous posts like “Pets and Mental Health“, “Can You ‘Grow Out Of’ Childhood OCD?“, and “What’s the Deal with MTHFR and Psychiatric Conditions?” My intention is to take an objective look at recent research, let it percolate through my noggin while I sift through the dozens of tabs I’ve amassed in Google Scholar, then report back with what I think are some important takeaways.


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Here in the northern hemisphere, we’re perched on the cusp of spring, and boy, am I ready to get outside. I live in Colorado, and hiking is one of, if not the most, enjoyable ways I spend my time in the warmer months. I’ve been gazing longingly at the mountains, perusing dog backpacks (that’s backpacks for dogs to wear) on Amazon, and figuratively dusting off my trail map app in anticipation. It could just be that I’m particularly drawn to being outside because of my personality and upbringing, but I’ve recently come across some buzz surrounding the positive effects that nature has on our emotional and physical health. So, I figured, what better way to become even more entrenched in spring fever than to spend a few hours reading about the outdoors?

So Many Studies

Nearly every article I’ve read so far has referenced a study published in 1984 by RS Ulrich. The study looked at a group of 46 hospital patients, all of whom had their gallbladders removed and were monitored postoperatively. 23 patients stayed in rooms with views of trees, while the other 23 had views of a brick wall. The now classic study found that the patients who had views of trees recovered faster and required less pain medication than the other group of patients.

From what I can tell, the Ulrich study seems to have sparked an interest in, and an understanding of, how nature might benefit us. Countless subsequent studies have been conducted that suggest that exposure to nature reduces blood pressure and increases positive affect, promotes healthy composition of microbiota involved in immune functioning, and lowers mortality from circulatory disease. In terms of emotional health, nature is associated with reduced stress and decreased activation in an area of the prefrontal cortex associated with rumination and mental illness. Higher vegetation cover is associated with a lower prevalence of depression and anxiety. Even potted plants have been found to increase the quality of life for employees in office settings.

What’s in a Dose of Nature?

Nature has the power to make us feel better, but what is it about being outside that has this effect?

Species Richness and Biodiversity

“Nature is not biodiversity, nor a proxy for biodiversity, but certainly encompasses biodiversity.”

Sandifer et al., 2015

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Increasingly, researchers are investigating the relationship between biodiversity in green spaces and psychological benefits. Several studies have found significant associations between higher plant and bird diversity and positive mental effects. A 2007 study by Fuller et al. found a positive correlation between plant species richness and participants’ sense of identity and ability to reflect. The 312 participants were fairly accurate at assessing plant species richness, which muddies causality. The question then becomes: are the benefits derived from species richness or perceived species richness?

Here’s another study to elaborate on that distinction. Researchers here found that psychological benefits of nature exposure were correlated not with biodiversity, but with participants’ perception of biodiversity only. In this study, participants were apparently not at all good at estimating species richness, and it affected their experience of being outside, regardless of how many species were actually present.

Frequency and Duration

So it seems that the more varied and species-rich the environment, the better. But is glancing out a window now and then the same as going for a walk outside, psychologically? I’d say no, but that doesn’t mean that short exposures to nature don’t benefit us. After all, just a 40-second break to look at a green, plant-filled roof has been shown to improve attention and performance on cognitive tasks, as compared to a break of the same length with views of concrete roofs.

In a sample of over 1500 Australian respondents, longer duration of nature excursions is associated with decreased prevalence of depression and high blood pressure. More frequent visits to public green spaces are associated with a greater sense of social cohesion, which I imagine contributes positively to mental health in general.

Criticisms

Few studies on this topic take an epidemiological approach, leading some to point out that we have very little data on long-term, population-level health effects of nature exposure. Criticisms of some studies also include sample size, lack of adequate controls, and statistical rigor. However, the number of studies that demonstrate a correlation between nature exposure and psychological benefit vastly outweigh the number of studies that show no relationship. While this does not negate the weaknesses mentioned previously, it does seem to suggest that there is validity to the idea that nature is emotionally beneficial.

The Daffodils are Blooming

All the signs that winter is ending are here; the daffodils are blooming, more birds are singing, the neighbors are cleaning out their garage, and before spring really gets underway, Colorado is scheduled to get one or two more last-minute dumps of snow.

Speaking of, now that I’ve gotten myself extra excited to get outside and let my brain soak in the wonderful sights, sounds, and smells of spring, it’s time to prepare myself for tonight’s snowstorm.

Dear Spring, please hurry.

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Can You “Grow Out Of” Childhood OCD?

When I was 10, I felt compelled to tell my parents “I love you” every time they left the house. Going to the grocery store? I love you. Going to work? I love you. Going to the mailbox? I love you. The fear that something catastrophic will happen to family members is a common manifestation of childhood and adolescent OCD. I thought that if I failed to carry out this ritual, my parents wouldn’t know that I loved them if or when something terrible occurred. I was also preoccupied with germs; my hands were cracked and bleeding from excessive washing and I worried constantly about contamination. I always walked a specific pattern on the rug in the hallway, and I carefully watched the family dog to be sure I’d notice when he winked at me–so that I could wink back. I couldn’t tell you why I had to wink at the dog, I just had to.

I knew that these behaviors were irrational, and yet the anxiety it caused me to resist the compulsions seemed unbearable. I was afraid to go to sleep because I worried I might sleepwalk and harm my family in the middle of the night. Nearly every evening, I would tearfully confess my intrusive thoughts to my mother, convinced that she would be afraid of me for thinking such awful things. OCD commanded almost every aspect of my life.

Did I Grow Out Of It?

My parents tried to get me into therapy, but I was shy and ashamed, and simply refused to participate. So, I started taking an SSRI, slowly titrating up to the maximum dose. And incredibly, it worked. Suddenly, I was free from the torturous anxiety and embarrassing compulsions. I could be a kid again. Two years on, I slowly came off my medication. We waited, on edge, for symptoms to return, but they never did. I’ve often wondered why I never relapsed. It seemed impossible that something that had plagued me for so long had just vanished.

Thanks, PubMed

I wanted to know if other people had experiences similar to mine, so I headed over to trusty ol’ PubMed. I found several articles that explore the topic of OCD remission. Some have woefully small sample sizes and others are barely longitudinal, but there does seem to be a higher rate of OCD remission in the pediatric population than the adult population. The factors that influence this aren’t very well understood; some studies show that an earlier onset of symptoms predicts better outcomes, while others associate earlier onset with chronic, adult OCD. Don’t you just love conflicting results? I do, however, think these results can be reconciled.

Maybe It’s About Treatment, Not Age

A study published in 2014 followed up with children and adults with OCD over a three year period. Children achieved remission more quickly than adults who had juvenile-onset of symptoms, but the age of onset did not affect the likelihood of remission. Instead, the authors show that the less time passes between the onset of symptoms and receiving treatment, the better the outcome. Unfortunately, this fits with the statistics on OCD treatment. In a different study by the same authors, children went an average of 1.5 years before receiving treatment, whereas adults reported a wide range of latency periods. On average, they went 14.5 years before receiving treatment, although the standard deviation was close to 12 years. Clearly, some adults suffer in silence for decades before getting treatment. It’s plausible, then, that children who receive treatment soon after developing symptoms see remission more often, but children who endure a longer period of uninterrupted symptoms are more likely to have chronic OCD into adulthood.

The Takeaway

Multiple studies emphasized the importance of early recognition and treatment of childhood-onset OCD. Overall, I was encouraged by what I found on my deep dive into the literature. The sources I found all seemed to agree; long-term persistence of childhood-onset OCD is less common than it is for adult-onset OCD.

After all this, I’m still not sure whether I grew out of OCD. It’s difficult to determine whether anybody grows out of it without treatment because study samples come largely from inpatient and outpatient treatment centers. I will say that I occasionally get a sticky thought that reeks of OCD, but I set it aside fairly easily. In a completely anecdotal way, this seems to me like the pathways that I was stuck in as a child had a chance to be rewired while I was on medication. Now, my brain can cope with intrusive thoughts pretty much like anybody else’s. Treatment with ERP and medication offers adults and children relief from their OCD symptoms. If I had known that the chances were pretty good that I wouldn’t suffer from OCD forever, it might have been a little easier to cope as a child. So, if you have a kid with OCD, know that remission is possible. And for all the adults with OCD, know that there is hope and you are not alone. Adults absolutely achieve remission as well. A 40 year follow up study found that of 251 participants, improvement was observed in 83%. Those are pretty good odds!