When it comes to dealing with anxiety disorders, Meredith Coles has no interest in modest goals.
“How grandiose do we want to be?” she said when asked about her dream for the field. “I don’t want anyone to have obsessive-compulsive disorder, ever again. That’s pretty grandiose.”
But Coles, director of the Binghamton Anxiety Clinic and an associate professor of psychology at Binghamton University, has mapped out an ambitious plan that just might do it. She envisions a combination of research projects to promote better outcomes and large-scale policy analysis to help set goals. Her work may lead to treatments for obsessive-compulsive disorder (OCD) and social anxiety disorder that are cheaper, more effective and more widely available.
OCD and social anxiety disorder have similar pathologies. The patient feels increasingly acute anxiety that’s alleviated either by avoiding social contact or through a ritual. A classic example of OCD is perpetual hand-washing. Patients with social anxiety disorder often avoid situations such as giving speeches or interacting with strangers.
A certain level of anxiety is normal and perhaps even healthy. Fearing flat tires may encourage a driver to check tire pressure regularly. The problem is when the anxiety is associated with dysfunctional behavior. And the difficult part of both ailments is that, left untreated, they rarely go away on their own. In fact, strategies people employ to cope with the disorders may offer short-term relief but ultimately reinforce the anxiety: You get out of giving a speech, let’s say, but the next time you have to prepare one, you’ll be even more anxious.
Coles and her staff have already looked at some of the roots of the disorders, including research that points out the difficulty patients have in perceiving the reality around them. One paper by a graduate assistant showed that people with social anxiety disorder often focus on less emotive parts of the face, so they have problems perceiving reaction to social interaction. Other research suggests a difficulty assessing the legitimacy of threats.
“We have treatment, and it works,” said Coles, whose treatment focuses on cognitive and behavioral methods.
But the current treatment can’t cure everyone. In fact, most patients continue to experience symptoms of the disorders.
Early diagnosis and treatment are critical, Coles said, because that prevents years of suffering and impairment. The longer a patient has OCD or social anxiety disorder, the more likely he is to develop additional problems such as depression or substance abuse.
This is where her latest project — a large-scale quantitative study — takes the next step. Coles received a two-year, $400,000 grant from the National Institute for Mental Health to survey 500 people about barriers to seeking treatment for anxiety disorders.
Her preliminary data suggest most people delay treatment because they think they can cope without help. They can’t. Others may fear real or imagined stigma for seeking psychological help. Many people may not understand the disorder or may lack access to appropriate care. In fact, some of Coles’ patients travel three hours across to get to her campus clinic.
“There are so many people suffering and not seeking help,” Coles said. “I want to bring that up a step. Therapy helps. I want people to get it.”
But psychologists lack details of how different factors play into the delay, and how influential each factor is. “The majority of people never access treatment for anxiety disorders,” Coles said. “Can they recognize something is wrong? What do they know about anxiety disorders? Do they even know what they are?”
Her survey hopes to answer some of those questions.
Understanding what people know and think about OCD and anxiety disorders can help treatment at the personal and community levels, said Gail S. Steketee, dean of the Boston University School of Social Work. “The beginning part of any good therapy is education about these psychological issues,” she said. “We can also do this on a more mass-media level, and it has been pretty successful when you consider that the stigma of seeking help is much less today than a generation or two ago, thanks to magazines, newspapers, the Internet and so forth.”
In particular, Coles is interested in pediatric diagnosis and education. It’s an exercise in math: Almost all cases of OCD or social anxiety can be diagnosed by the time the patient is 21 years old. Many cases begin in childhood or adolescence. Yet previous research suggests that patients will delay treatment an average of nine years after they recognize they’re having trouble. And they don’t recognize they’re having trouble for five years following the point where they would receive a diagnosis.
“The younger we educate kids, the better off they’ll be,” said Coles, who serves on the Scientific Advisory Board of the Anxiety Disorders Association of America. “We need to prevent mental disease in kids.”
Australia already has programs in place to educate and screen children as young as 4 for anxiety disorders. Coles has looked into its health-care system to see what lessons America can learn.
Steketee hesitates to suggest that 4-year-olds need to be targeted for education, but certainly younger people in general must be. “It is reasonable to try to get education into the hands of parents and teachers of grade-school- age children, as early intervention is most likely to be helpful and to prevent worse problems,” she said. “But many people do not develop a serious OCD or social anxiety problem until their teenage years or their early 20s.”
The good news? They are older and can be more “rational” about the need for help. However, they are also in the throes of concern about what their peers would think if they knew about the problem.
“This and other factors delay the treatment-seeking process,” Steketee said. “Education that targets this young adult group would be especially helpful and is most likely to occur through the media.”
That brings Coles full circle: back to the focused research on outcomes and progression of OCD and social anxiety that constitutes about 90 percent of her work to date. If programs can be put in place to screen and educate children as young as 4, can that same mechanism be used to identify the predictors that lead to the diagnosis? And if the cause can be pinned down, can ways be developed to prevent OCD and social anxiety disorder?
These are big questions, and Coles completed a study in 2009 to begin answering them.
The data supported the hypothesis that cognitions are important in the development of OCD, Coles said. “Specifically, particular types of beliefs such as a heightened sense of personal responsibility to prevent harm, the likelihood of threat and the importance of and need to control one’s thoughts were related to increased levels of OCD symptoms over time.”
Further, she said, her study showed that combining those tendencies with a heightened self-consciousness proved to be useful in predicting OCD symptoms later on. She and her staff are continuing this research with a larger study examining multiple risk factors.
But awareness is only one aspect behind recognizing and treating OCD and social anxiety disorder, Steketee said. Stigma takes more time to address, especially because it’s a cultural factor. “Slowly but surely, we are breaking this barrier down,” she said, “and every famous person or person of power who stands up and admits a problem and how they are seeking help moves this effort forward.”
Steketee said informing mental-health professionals about effective treatment methods is also a challenge. “Most clinicians want to do the right thing to help their patients/clients, but adopting new methods seems harder than it should be,” she said. “Moving mental-health research into practice is a major goal of nearly every national mental-health professional organization and of the federal government.”
Overcoming those stumbling blocks will have major implications for people with anxiety disorders and public-policy makers. Early intervention, Coles said, can mean:
- Less dysfunction with the incumbent loss of productivity
- Less expertise needed to treat the disorder
- Less money spent to provide that treatment
At least that’s the assumption, Coles said. Proving it is another question.
“There’s always another question,” she said. “I’m always asking another question.”
And Coles isn’t afraid to ask the grandiose one, too.
Visit go.binghamton.edu/coles to see a video featuring Meredith Coles talking about her research.