The New Image of OCD
By Loretta Marmer
IT'S 11 P.M. AS STACI SETTLES INTO BED FOR THE NIGHT. Exhausted, she turns out the light and pulls up the covers. Then the nagging thoughts begin. Are the doors locked? Did I turn off the coffee maker? The stove? The lights?
Groggy, she drags herself out of bed and checks to make sure her home is safe. She returns to bed, knowing everything is fine. Yet the intrusive thoughts won't quit. Again, she goes downstairs to check the doors and appliances. Staci repeats her ritual at least a dozen times before she finally drifts off to sleep shortly after 2 a.m.
Staci's checking ritual is a classic sign of obsessive-compulsive disorder (OCD), and she is not alone. Thought to be rare only 15 years ago, OCD is now recognized as one of the most common--and most treatable--neuropsychiatric disorders. Symptoms can range from those that are merely annoying to those that are actually disabling.
Obsessions or compulsions that take at least an hour each day are considered disabling. However, people with OCD typically spend many hours a day obsessing before they seek professional help. Besides having their time stolen by OCD, many people experience a "mental hell" as a result of the condition. Often, its symptoms make school, work or social life impossible.
The Obsessive-Compulsive Foundation (OCF), defines obsessions as "unwanted, intrusive ideas, images, impulses, or worries that run through a person's mind repeatedly." Obsessions are usually senseless, unpleasant, distasteful and typically involve themes of harm.
Founded in 1986, the OCF is a worldwide, not-for-profit organization dedicated to increasing public awareness of the disorder, as well as providing support and information to those who have OCD, their family and friends, and medical professionals.
People with OCD may experience incessant worries about dirt, germs, contamination, infection, and contagion. Other common obsessions include recurrent thoughts that something has not been done properly (even though the individual knows it has); repeated impulses to kill a beloved family member; the feeling that certain things must always be in a certain place, position, or order; worries about the shape or functioning of body parts; obsession with nonsensical sounds, words, numbers, or images; and fear of disease.
Compulsions can be physical actions or mental thoughts which are repeated in response to an obsession. According to the Foundation literature, individuals with OCD feel the need to perform rituals in a specific manner or even according to self-prescribed "rules." Ritualistic behaviors do not provide pleasure but are continued because they reduce tension, discomfort, or anxiety associated with obsessions.
Children with OCD seem more likely to have additional psychiatric problems than those who do not have the disorder. Conditions that frequently occur along with OCD include anxiety disorders depression/dysthymia, disruptive behavior disorders, learning disorders, tic disorders/Tourette's syndrome, trichotillomania (hair pulling) and body dysmorphic disorder.
The exact cause(s) of OCD remains unclear, according to J. Jay Fruehling, MA, information specialist, for the Child Psychopharmacology Information Service, University of Wisconsin-Madison, Department of Psychiatry. "However, it is known that OCD is related to disturbances in brain functioning ...These...are not fully understood, but it seems certain they involve the brain chemical serotonin." Most doctors agree that OCD is related to genetics, and that the disorder is not caused by bad or incompetent parenting, according to a pamphlet Fruehling wrote for the OCF.
Selecting treatment depends on the age of the patient and the severity of the illness. OCD experts usually treat the condition with cognitive behavioral therapy (CBT) alone, medication alone, or a combination of CBT and drugs.
Cognitive behavioral therapy involves a combination of exposure and response or ritual prevention. Exposure capitalizes on the fact that anxiety usually attenuates after sufficient duration or contact with a feared stimulus. Patients who fear germs, for example, must handle "germy" objects until their anxiety diminishes. Response prevention calls for the patients to refrain from ritualized or avoidance behaviors.
In a recent issue of the OCF Newsletter, Holly S. describes how these techniques helped her work through her lifelong struggle with OCD. In "Fighting for My Life: The Journey Out of OCD Hell," Holly recalls her days as a young medical student.
"I was paralyzed by the fear that I would catch the (AIDS) virus from a door handle, an elevator button, or a sneeze from a fellow commuter on the subway. Anything red was surely HIV-infected blood, and every man I saw was a potentially lethal carrier...The intelligent, rational woman who had recently gained honors in microbiology class knew that these fears were ridiculous, and was ashamed of the obsessive and compulsive fear-driven person walking around in her shoes. Who was this crazy person I had become?"
With the help of her behavior therapist, psychiatrist, social worker, and several counselors, Holly designed a program to immerse herself in her most feared situations.
"I shadowed a lab technician as she drew blood. I touched red spots and stains daily. I abstained from hand washing completely for almost a week (wearing gloves to shower, to prepare food, and to use the toilet). I 'contaminated' objects in the house. I slept with a butcher knife by my bed. I rubbed the bottoms of my shoes daily. I accompanied a doctor in an HIV clinic. I attended plays about AIDS. I went to a volunteer orientation at the AIDS Action Committee. I had a massage by an HIV-infected massage therapist. I shadowed an emergency-room doctor for a night, and I rubbed my hands on toilet seats, subway railings, mailboxes and public phones. I crumpled leaves in my hands, sprayed Raid on things, including my own hands, and I hated every minute of it. It was terrifying, uncomfortable, anxiety-provoking, and just plain yucky."
Although the therapy was painful, Holly is grateful for the change it has made in her life. "...Absolutely nothing compares to the pride and gratitude I feel for the behavior-therapy work I have done and the people who have helped me. It is by far my greatest accomplishment... It is a work still in progress...What I must do to maintain my gains is simple, yet crucial to my ongoing recovery. I must take my medication regularly, get plenty of sleep, exercise moderately, and stay connected to my support network (which means going to my mutual support group and contacting my behavior therapist when I feel the need for a booster session)," she writes.
Despite the proven success of CBT, a recent survey of OCF's membership revealed that only 40 percent of the respondents had ever been in behavior therapy. The foundation is conducting regional behavior therapy institutes throughout the United States to increase the availability of high-quality behavior therapy to individuals with OCD.
CBT is not the only hope for people battling OCD. According to Michael A. Jenike, MD, Professor of Psychiatry, Harvard Medical School and chairman of the OCF Scientific Advisory Board, five drugs have been shown to be particularly useful in double-blind, placebo-controlled studies These are: fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and clomipramine (Anafranil). The latter has been around the longest, and it is the best studied throughout the world, but there is growing evidence that the other drugs are as effective.
Each of these drugs has potent effects on serotonin, a neurotransmitter, or chemical messenger, in the brain, states Dr. Jenike in his special report published by the OCF. "It appears that potent effects on brain serotonin are necessary (but not sufficient) to produce improvement in OCD," he wrote.
The anti-obsessional drugs, known as serotonin reuptake inhibitors (SRIs), work by slowing the reuptake of serotonin, making it more available to the receiving cell and prolonging its effect on the brain. "We think that this increased serotonin produces changes, over a period of a few weeks, in receptors (areas where serotonin attaches) in some of the membranes of the nerves. We also believe that these receptors may be abnormal in patients with OCD, and that the changes that occur in them due to these medications at least partly reverse the OCD symptoms. This is only part of how drugs work; it is very likely that other brain chemicals in addition to serotonin are involved," he stated.
Meanwhile researchers continue to explore other methods of treating people with OCD. Pfizer Inc.; the Dean Foundation for Health, Research and Education; Massachusetts General Hospital; and the Institute of Psychiatry of London are currently conducting a multi-site, randomized, controlled trial to examine the benefits of a computer-assisted behavioral treatment program (BT STEPS), clinician-administered behavior therapy and systematic relaxation for treating OCD.
According to a foundation press release issued earlier this year, "BT STEPS is a computer-administered, self-help behavioral treatment program that assists patients in the assessment of their OCD and then helps them design and implement their own treatment program."
The study includes 240 patients randomized into one of three treatment arms. Treatment lasts 12 weeks, and patients meet with the study staff five times during the study. Patients who do not respond to treatment are eligible to participate in an extension study. Sites are located in: Atlanta, GA; Worcester, MA; Raleigh, NC; Toronto, Canada; Houston, TX; Gainesville, FL; Wheat Ridge, CO; and Salt Lake City, UT.
For more information contact the OCF, 9 Depot Street Milford, CT 06460; (203) 878-5669 (phone) or (203) 874-2826 (fax).
Loretta Marmer is a freelance writer for ADVANCE.