Drug treatment tames obsessive-compulsive disorder – Cover Story
In the late 1980s, a number of people appeared on TV shows to talk about a condition that had nearly wrecked their lives: obsessive-compulsive disorder (OCD). They wanted to tell fellow sufferers how they were being helped, even cured, of this distressing disorder by an experimental drug.
At that time, OCD was thought to be comparatively rare. But, surprisingly, in response to the TV programs, thousands of people called or wrote in from all over the country, expressing relief that there were others with the same problem. When Ann Landers ran a column about OCD, she was deluged with 8,000 letters in one week.
If people with OCD didn’t know they had a lot of company-maybe as many as 5 million people in the United States-it’s because most feel ashamed and try as much as possible to keep their behavior hidden from other people.
And they succeed remarkably well. Sigmund Freud noted that people who have this disorder are adept at concealment because they function well during a part of the day, once they have devoted a number of hours to their “secret doings.”
What are the secret doings that Freud speaks of? They are repetitive acts called compulsions, performed to relieve anxiety caused by obsessive thoughts or urges or images. Individuals with OCD realize that these thoughts are senseless and struggle unsuccessfully to resist them. They know that the compulsive actions, or rituals, they perform are also senseless, but feel that if they don’t do them, something bad will happen to them or others.
The most common obsessions include:
* fear of contagion or contamination: “Everything I touch is full of germs.”
* fear of violent or aggressive actions toward oneself or others: “I’m going to stab my mother.”
* doubt: Did I hit that child with my car at that last intersection?”
Other frequent obsessions are concerned with:
* orderliness: “I can’t go to school until everything in my room is in perfect order.”
* continual sexual fantasies that dominate thought processes
* thoughts the person considers blasphemous
* repetition of numbers, tunes, words, or sounds.
In response to fears of contagion, the person with OCD goes overboard about cleanliness and is compelled to wash hands or shower for several hours a day. Michael A. Jenike, M.D., of Boston’s Massachusetts General Hospital, writes in the Aug. 24, 1989, New England Journal of Medicine, that a recent study revealed that 37 percent of the patients who visited a dermatology clinic with nonspecific dermatitis had OCD, though none had sought treatment for it. Cleaners,” as these compulsive washers are called, constitute about 85 percent of those afflicted.
Less familiar are checkers,” who, because they doubt the evidence of their senses, are compelled, for example, to continually check with their mothers to make sure they haven’t stabbed them, or repeatedly visit the scene of an imagined accident to be certain they have not run over a child.
“Hoarders” may save every piece of mail they’ve ever received-every scrap of paper they’ve picked up on the street, even Christmas trees from years past-for fear that they’ll throw out something valuable.
Other compulsions take the form of routines: Some OCD sufferers are compelled to jump over every crack in the sidewalk (shades of childhood), touch every light pole they pass, or go from the car to the front door in a certain way-four steps forward, two steps back, sing one refrain of “Yankee Doodle Dandy,” four steps forward, and so forth, to the despair of their families and possible amusement of the neighbors. Such a routine may stretch a 20-second walk to 20 minutes.
Everybody feels obsessive or compulsive at times. These can be positive traits. At their grandest they may be magnificent obsessions that result in cures for disease or scientific discoveries that benefit all. On a less significant level, they can be an occasional illogical thought, or certain habitual and rigid ways of doing things. Some people must straighten every crooked picture on the walls or they are not comfortable. Others can’t rest until every used dish or glass is washed and put away for the night. This is not OCD. The American Psychiatric Association says that the essential feature of OCD is recurrent obsessions or compulsions, or both, sufficiently severe to cause marked distress, be time-consuming (over one hour a day), or significantly interfere with a person’s normal routine.
Degrees of Disorder
There are degrees of the disorder. Most people with OCD carry on with their lives, giving in to their compulsions temporarily, usually in the privacy of the home. Others go through phases of OCD behavior with complete remission between episodes. Family members often become involved in the rituals to keep peace in the household, for example, rising from their beds at night to aid the “checker”-for the twentieth time-in seeing that all the doors are locked and all the appliances are off.
For about 10 percent of those afflicted, the disorder is chronic and disabling. Days, even nights, are consumed by rituals that prevent them from functioning normally, if at all. Many cannot hold down a job, others are afraid to marry, because their rituals would be revealed. OCD people find no pleasure in their rituals, only temporary relief from anxiety. Without treatment, OCD may last a lifetime.
In childhood, boys with OCD outnumber girls by about 3 to 1. OCD may appear as early as 2 years of age as compulsions, though it usually begins in adolescence. Compulsions may take different forms at different ages. Judith L. Rapoport, M.D., author of The Boy Who Couldn’t Stop Washing, tells of a boy who walked in circles around manhole covers at the age of 2. At 12 he was unable to attend school because of a bizarre compulsion to draw O’s.
While diagnosis in children is easy when symptoms are obvious, parents should be alert to more subtle signs, such as too much time spent on homework with no results, frequent erasures on homework or tests, a puzzling increase in laundry and utility bills, stopped-up toilets because of overuse of toilet paper, overlong bedtime rituals, hoarding of useless things, or frequent requests for reassurance.
In adulthood, the disorder is divided almost evenly between men and women, and the average age of onset is about 22. OCD affects people in all ethnic groups and cultures worldwide.
No one knows exactly what causes OCD, but researchers believe it is biochemical in origin, at least in the most severe cases. About 20 percent of people with OCD have family members who also have the disorder, although different rituals be practiced by each affected family member.
Researchers have found considerable evidence suggesting abnormalities in functioning of one or more neurotransmitters, chemicals that act as messengers between brain cells. The neurotransmitter thought to be most prominently involved in OCD is serotonin, which plays an important role in the brain in regulating activities such as sleep, mood, aggression, and repetitive behaviors. Investigators using imaging techniques-such as positron emission tomography (PET), x-ray computed tomography (CT), or magnetic resonance imaging (MRI)-have reported abnormalities in the brains of people with OCD, especially in the frontal lobe. Researchers think that overactivity of this part of the brain leads to excessive concern with fastidiousness, order and meticulousness.
Some who suffer from OCD display other neurological symptoms. About 20 percent have tics, such as eye-blinking or facial grimacing. People with Sydenham’s chorea (characterized by involuntary movements of the face and extremities), epilepsy, and postencephalitic Parkinson’s disease may exhibit symptoms of OCD because these conditions involve the same part of the brain. Ten percent of schizophrenics display OCD symptoms.
“OCD is as much an illness as diabetes,” says John S. March, M.D., M.Ph., director of the program in child and adolescent anxiety disorders at Duke University. “On the other hand, the concordance rates for OCD between identical twins aren’t 100 percent, so there are obviously some environmental factors that play a role as well. People have families and stories and life histories that contribute to whether or not the child with OCD has an easy time of it or a more difficult time. There is a kind of interplay between environmental factors and the biological vulnerability that is required for the disorder. I really treat this as a biological disturbance, but it’s not like treating strep throat with penicillin. Each kid is different.”
Some experts believe that a technique called behavior therapy works better than traditional psychotherapy in treating OCD. The therapist exposes the individual to what is feared, but prevents the usual response, or rituals. Simply explained, someone who cannot bear shaking hands without washing 20 times a day agrees to shake hands with one person, but not to wash afterward. As the treatment progresses, the therapist encourages the patient to do more and more handshaking, also without washing. As the patient realizes nothing bad has happened from being unwashed, anxiety levels diminish and rituals disappear. When successful, treatment goes quickly, with improvement seen in a matter of weeks for 60 to 70 percent of patients.
Help is also available in the form of medication. Anafranil (clomipramine), the drug taken by the OCD sufferers appearing on TV talk shows several years back, was approved by FDA late in 1989 specifically for OCD. Another drug, Prozac (fluoxetine), approved for depression but not OCD, has been reported to be effective. Both Anafranil and Prozac were developed as antidepressants and appear to increase the availability of serotonin in the brain.
While some patients on Anafranil show improvement in a matter of weeks, it may take as long as three months for the drug to take effect. Side effects include constipation, dry mouth, blurred vision, sexual dysfunction, dizziness, and weight gain. Other drugs being investigated include fluvoxamine, sertraline and paroxetine.
It is not known at this time whether OCD patients will have to remain on drugs indefinitely. Some are so improved that they stop medication after a year or two, gradually reducing the doses. Other patients seem to need medication on a more prolonged basis. A small percentage of patients cannot take either drug because of side effects.
While either behavior therapy or drug therapy can be used alone, some experts report that a combination of the two produces the best outcome. Patricia Perkins, the president of the OC Foundation, says: “You’ve got two things going on here. You’ve got a biochemical imbalance, plus all of these behaviors that are coping mechanisms put in place since childhood to cope with the anxiety that is the real disease. You need behavior therapy to get rid of the habit side. The brain is now O.K., but if for 15 years you haven’t touched a doorknob because it’s full of germs, someone has to help you touch it the first time to realize that no longer are you going to feel the terrible anxiety you used to feel.”
Evelvn Zamula is a freelance writer in Potomac, Md.
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