The chemistry of doubt

The chemistry of doubt – obsessive-compulsive disorder

Pamela King

The Chemistry of Doubt

The world of obsessive-compulsive disorder (OCD) is an eerie one where normal habits spin out of control. When Patrick Johnson was 8 years old, stairs suddenly became a treadmill. “At first I’d walk up and down the stairs only three to four times. Later I had to run up and down 63 times in 45 minutes. If I failed, I had to start all over again from the beginning. Then other weird behaviors, such as compulsive washing, started to kick in, increased, multiplied and became very precise and very exacting. They took on a life of their own and became the enemy. I led two lives — one a hidden nightmare, the other normal.”

Johnson’s perfectionistic rituals and repetitive thoughts crippled his life for 20 years. Obsessive-compulsive are consigned to a hell in which they repeat and rehearse normal doubts and daily routines, sometimes hundreds of times a day. The basic difference between obsessives and compulsives is the difference between thought and action. Obsessives may be immobilized by horrifying yet irresistible thoughts of stabbing a child, for instance, while some compulsives bloody their hands, as Johnson did, after 16 hours of washing away imaginary germs. Although they know they are being irrational, they simply cannot stop. Certainty vanishes: “But how can I be certain I won’t plunge a knife into someone?” “How do I know my hands are clean?” They doubt the evidence of their own senses.

OCD usually begins in the late teens and early 20s and affects both men and women about equally. Ashamed of their bizarre behavior, obsessive-compulsives typically wait years before seeking treatment. By the time Johnson went for help he had endured eight years of an endless labyrinth of rituals. The torture and despair of OCD often lead its victims into serious depression and, occasionally, suicide attempts.

Once thought to be relatively rare, OCD is now known to affect approximately 5 million Americans. Recent research is providing clues — and some hope for effective treatment — for what the French label the “doubting disease.”

Positron emission tomography (PET) and other new brain-imaging techniques indicate a neurological basis for this illness. Abnormalities in the basal ganglia, a portion of the “primitive” brain that serves as a sort of relay station between our senses, motor functions and higher brain functions in the cortex, are one suspected cause.

According to psychiatrist Judith Rapoport of the National Institute of Mental Health, who has specialized in OCD research for 17 years, these abnormalities may be a neurological misfiring, a sort of hiccup, in the caudate nucleus buried deep within the basal ganglia. And there may be a genetic basis for the disease; OCD runs in families.

Rapoport also sees a model in animal behavior for the patterns that ensnare obsessive-compulsives in all cultures — the washing, the doorway rituals such as spinning three times before crossing a threshold, the irrational hoarding. She suspects that if a neurological misfiring is at the root of the disease, it affects the equivalent of grooming, hoarding and nesting instincts programmed into human brains at an earlier evolutionary stage.

“The built-in patterns document some stored knowledge that serves an ancient purpose,” she explains. “Cleaning, avoiding, checking and repeating relate to the most basic preoccupations of cleanliness, safety, aggression and sex. . . . The most convincing evidence will come when we find key releasers of these behaviors, analogous to the hormones that typically set off such patterns in animals.”

For years Freudian analysts argued that OCD resulted from repressed conflicts around aggression, power struggles in the family or forbidden wishes. But psychoanalysis, it turns out, may be the least helpful therapy for victims of OCD. The two most effective treatments are drug therapy and behavior modification.

One drug, clomipramine (trade name Anafranil), promises release from the torment of OCD for about 70% of those it enslaves. Clomipramine — an antidepressant recently approved by the Food and Drug Administration (FDA) for restricted, experimental use in the United States — has been widely used in Europe for the past 20 years to combat depression and more recently to alleviate obsessions and compulsions. But until the FDA’s recent approval, Americans suffering from OCD — at least those who could afford to — traveled to Canada, Mexico and Europe for the drug.

With clomipramine more widely available in this country, someone like Johnson can reduce the amount of time spent in the relentless grip of obsessions or compulsions from hours to minutes.

How the drug works or why it works for one person and not another is unclear, but one theory is that it increases the brain’s levels of serotonin, a neurotransmitter thought to be involved in producing calmness. Like other drugs effective in relieving OCD’s symptoms, clomipramine appears to block the reabsorption of serotonin from the synapse to the firing neuron.

However, other neurotransmitters also seem to be involved. Research by psychiatrist Pedro Delgado at Yale University indicates that serotonin may not be the sole link to treating OCD. Using dietary restrictions, Delgado temporarily depleted serotonin in the brains of patients with both OCD and depression who were being treated with an antidepressant that, like clomipramine, makes serotonin more readily available. Delgado found that depression worsened when serotonin was depleted, while obsessions and compulsions did not. According to Delgado, this suggests that other neurotransmitters probably are involved in OCD and need to be explored.

Psychiatrists Christopher J. McDougle and Wayne K. Goodman, also at Yale, are investigating the role that dopamine, a neurotransmitter implicated in thought and movement disorders, may play in OCD. In a group of OCD patients who failed to respond to antidepressants, the researchers found that adding a dopamine inhibitor greatly reduced the symptoms in more than half the patients. McDougle speculates that “irregularities in both the dopamine and serotonin systems may somehow interact to produce OCD symptoms in some patients. And the fact that only about half of the patients improved with the combined treatment indicates the possibility that additional neurotransmitter systems may ultimately be implicated.”

Psychiatrist Michael Liebowitz of Columbia University and colleagues speculate that serotonin may be related to the lack of certainty typical in OCD, while noradrenaline, a neurotransmitter involved in the body’s stress response, may cause the anxiety that accompanies an obsessive-compulsive episode.

Behavior-modification therapy has also been found to help OCD. Some specialists advocate a technique known as “implosion,” in which patients are forced to confront their fears head-on. Patients who are overly fearful of contamination might be instructed, for example, to wear the same clothes for five days or to go for a week without showering. “It increases the patient’s fear for a while,” says psychologist Edna Foa of the Medical College of Pennsylvania, “but within a few weeks they get so much better that you don’t recognize them.” Foa claims a success rate with behavior modification of 65% to 70%, which matches that of clomipramine.

A combination of drugs and therapy has freed Johnson from his compulsions and obsessions for almost two years now. “Every thought or action used to be a potential attack,” he says. “I was always battling established compulsions or defending against the onset of new ones. I can’t tell you how wonderful it feels to think freely, to just let the thoughts flow in and flow out; they’re no longer the enemy.”

COPYRIGHT 1989 Sussex Publishers, Inc.

COPYRIGHT 2004 Gale Group