+ Obsessive-Compulsive Disorder: OCD

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An article in Time Magazine by Jeffrey Kruger describes the difficulties that haunt a person with OCD (obsessive-compulsive disorder).   He describes a man leaving work whose car bumps a pothole cover.  He had seen a child on a bike: had he hit the child?  The driver circles back and back and back for hours, checking everything around, before he can finally allow himself to complete the drive home.

A little anxiety is a good thing.  Cavemen needed to know there was no lion near the family cave.  They also needed to be able to imagine places the lion might be.  “There’s a creative, ‘what if’ quality to this thinking,” says clinical psychologist Jonathan Grayson of the Anxiety and Agoraphobia Treatment Center in Bala Cynwyd, Pennsylvania.  “It’s evolutionarily valuable.” 

Seven million adults, teens and children in the US are now thought to have OCD in one form or another.  Most of them hide it.  Since one family member disabled by the disorder can destabilize an entire household, a single case can mean several collateral victims. 

Judith Rapaport, chief of child psyciatry at the National Institute of Mental Health and author of “The Boy Who Couldn’t Stop Washing”, says, “Having these traits is a universal experience.  You have to show long-standing interference with function, and that eliminates most people.” 

“Everyone has intrusive thoughts, but most people consider them meaningless and can move on with their lives,” asserts psychologist Sabine Wilhelm, associate professor at Harvard Medical School and director of the OCD clinic at Massachusetts General Hospital.  “For people with OCD, the thoughts become their lives.” 

OCD often masquerades as other things: depression, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), autism, even schizophrenia.

Since victims often conceal their problems for years, they ensure that no diagnosis, right or wrong, can begin to be made.  The average lag time between onset and diagnosis is thought to be 9 years; it is often as many as 8 years more before effective treatment is prescribed.  Entire childhoods, entire careers can be lost.

What Causes OCD? 

OCD is a neurochemical storm in the brain.  For years, diagnosticians had assumed it was caused by the almond-shaped structure called the amygdala.  Researchers now know that the orbital frontal cortex and the caudate nucleus (seated high in the brain), and the thalamus (lying deeper) are also players.

“These areas are linked along a circuit,” says Dr. Sanjaya Saxena, director of the OCD program at UC San Diego.  That particular wiring is supposed to regulate your response to the stimuli around you, including how anxious you are in the face of threatening or frustrating events.  “That circuit,” says Saxena, “is abnormally active in people with OCD.”

“OCD has had a slow research start, says Gerald Nestadt, co-director of the OCD clinic at Johs-Hopkins University.  But all that is changing.  A burst of new genetics studies is turning up insights; scanning technologies are pinpointing the parts of the brain that trigger the symptoms.  

Compelling, if controversial, research, has linked OCD to infection.  Investigators at the University of Chicago and the University of Washington studied a group of 144 children — 71% of whom were boys — who had tics or OCD.  All the kids, it turned out, were more than twice as likely to have had a strep infection in the previous three months.  For those with Tourette’s symptoms, the strep incidence was a whopping 13 times as great.  The tics and OCD are probably an autoimmune response, according to this theory.

Fixing OCD:  Options 

The first step, no matter how or when the disorder hits, is usually comparatively short-term behavioral therapy, using a technique known as exposure and response prevention (ERP).  In this method, OCD sufferers don’t try to avoid their source of anxiety but actually seek it out.  Eventually, the theory goes, emotional nerve endings grow desensitized to the stimulus.  The goal is to tough it out until that happens.

At the Obsessive Compulsive Foundation convention in Atlanta last summer, Jonathan Grayson offered some sufferers a quick taste of ERP.  He invited audience members with dirt and germ anxieties to come forward and sit beside him on the ballroom carpet.  He told them to touch the carpet and bring their fingers to their lips.

Left to themselves, most would have refused, or, if they went along, would have spent hours scrubbing in the bathroom afterward.  Instead, they sat with Grayson and the anxiety, learning that the pain does subside.

Extended treatment involves a graduated series of such exposures, each a bit more challenging.

Medication helps too.  Antidepressants such as Prozac and other selective serotonin reuptake inhibitors (SSRIs) can help quiet the anxiety enough that patients can begin ERP, and stay with it.  Practitioners are more reluctant to give medication to children, but they are careful not to stay with ERP alone for too long if it isn’t producing results.  “The longer a child struggles with an illness, the more impact it’s going to have,” says Dr John Piacentini of UCLA’s child OCD clinic.

A growing group of investigators are experimenting with drugs targeting glutamates.  The best medication so far (riluzole) was originally developed for Lou Gehrig’s disease.  In a small study at Yale, half the subjects experienced a 35% remission, and almost all the rest improved a little.

There is a much more invasive therapy  —  deep brain stimulation (DBS), in which electrodes are implanted in the brain and connected by wires embedded in the skin to a pacemaker-like device in the chest.  Low doses of current can then be applied as needed to calm the turmoil in certain areas of the brain.  It has already been used in about 35,000 people world-wide to treat Parkinson’s disease; FDA approval is pending for OCD treatment as well.

“Many of our OCD patients are able to re-engage in life rather than being stuck at home,” say neurosurgeon Ali Rezai of Cleveland Clinic, who performs DBS surgery for Parkinson’s and has researched it for OCD.

But for the vast majority of sufferers, the treatment never needs to go this far.

Sole source: (online) article in Time Magazine by Jeffrey Kluger with reporting by Dan Cray and Rachel Pomerance.  Article can be found at www.time.com

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