by Ginny Graves - last updated: March 09, 2009 [original link]
Experts define and explain how to cope with obsessive compulsive disorder and advise how to determine whether or not your ritualistic behaviors are normal or a sign of a serious anxiety problem.
Understanding the OCD brain
“When I was 4 years old, I’d brush the carpet in my room a certain way so I’d know if anyone walked in, and I was always straightening the dolls on my shelf,” Zurbuch recalls. “Everything was perfectly clean and nothing ever moved.”
Worse than her fear of disorder was her long-standing worry that harm would come to someone she loves. “I had daily rituals to protect loved ones. I knew intellectually that those rituals wouldn’t protect my family, but OCD isn’t an intellectual process,” she says. “I don’t know how to explain it except that the rituals were something I felt like I had to do.”
Although it’s tempting to think of OCD as a character flaw or eccentricity, experts say it’s a brain-based disorder. And more studies are starting to reveal the neurological underpinnings of the insistent thoughts, fears, and behaviors that besiege sufferers.
In a 2007 study, for instance, University of Cambridge researchers found that people with OCD have less gray matter in regions of the brain that play an important role in suppressing responses and habits. This “may contribute to the compulsive and repetitive behaviors,” Lara Menzies, the lead author of the study and a researcher in the university’s Brain Mapping Unit, has said.
Likewise, when researchers at the University of California, Los Angeles used positron emission tomography (PET) to look at the brains of people with OCD, they found a pattern of hyperactivity in particular circuits involved in habit formation, says Sanjaya Saxena, MD, who participated in the UCLA research and is now director of the Obsessive Compulsive Disorders Program at the University of California, San Diego. The affected brain areas identify danger, generate worry signals, and dictate how we respond to those emotional red flags.
Whether the brain abnormalities are the cause or result of OCD is unclear, but studies show that the disorder has a strong genetic component. Having a first-degree relative with OCD increases your risk of developing it fivefold. OCD probably involves malfunctions in several genes — glitches that researchers are starting to identify.
In fact, last year National Institutes of Mental Health researchers reported that several variations within a certain gene, known as the serotonin transporter gene, act together to increase the risk of OCD. The gene produces a protein that helps make serotonin, the brain chemical affected by Prozac and many other antidepressants, more available to brain cells. When the gene is overactive (as it seems to be in some people with OCD), too much serotonin is taken out between cells, leaving too little for the brain to use.
Not surprisingly, selective serotonin reuptake inhibitors (SSRIs) such as Prozac improve the symptoms for many people. “About 50 to 60% of patients respond to SSRIs, but it usually takes about 10 weeks and requires a higher dose than the treatment of depression,” says Elias Aboujaoude, MD, director of the Impulse Control Disorders Clinic at Stanford University and author of Compulsive Acts: A Psychiatrist’s Tales of Ritual and Obsession. Medications can improve symptoms substantially, but it may take trials of several drugs to find the one that works best, Dr. Aboujaoude says.
Life with OCD
For those who do have OCD (about 2 million people in the United States), it can be a hugely disabling illness. Sufferers are less likely than other people to get married and more likely to be unemployed and depressed. “People often keep their OCD secret because they feel ashamed of their unusual behavior, so it can take years for them to seek treatment,” says Michael Jenike, MD, professor of psychiatry at Harvard Medical School and the director of the Obsessive Compulsive Disorders Institute at McLean Hospital in Belmont, Massachusetts. Just going through the elaborate rituals that help someone with OCD get out the door can be exhausting.
Take Hilary Zurbuch, a 29-year-old from Pittsburgh. Each morning she used to make her bed, muss it, remake it, shower, and pick out perfectly matching clothes—similar colors, same brand, head to toe. She’d check the lock on her door five times before climbing into her immaculate Jeep to drive to work. On the way she’d listen to the same song, “April Showers” by Sugarland. “If I didn’t follow the same routine every day, I worried that something bad would happen,” she says.
Sheila Cavanaugh, 42, of Brownville Junction, Maine, may not make it out of the house at all. Even though she isn’t sick, she’s so concerned she’ll infect someone else with her germs that she rarely ventures out.
But there’s good news, whatever your level of obsessive compulsive behavior: Over the last decade or so, a flurry of research (some with high-tech imaging tools that let doctors peer into the brains of people with OCD) has yielded a better understanding of why some people’s disturbing thoughts and odd habits spin out of control. Here’s the latest thinking on obsessive compulsive behavior, and how to manage it.
When is a habit an illness?
Most people would never guess that Anne Coulter has struggled with OCD. A freelance writer with lots of friends and an active social life, she rarely checks her stove these days—but it wasn’t always so. Like many women with the illness, her symptoms have waxed and waned over the years, often in response to stress.
Coulter’s problems began in her early 20s, which is typical. Most people with OCD and similar disorders develop symptoms before age 36. And the earlier the illness crops up (one-third to one-half of sufferers show signs in childhood), the tougher it may be to treat. Why the illness appears earlier in some is a mystery, but there is evidence that some children (1 in 1,000) may develop the disorder after a strep infection, when an antibody generated to fight the bacteria mistakenly turns against a brain enzyme and disrupts communication between neurons.
Some OCD sufferers think a stressful event precipitated the onset of symptoms, but for Coulter they came out of the blue. At the time, she had a good job as a communications specialist with a consulting firm and was in a happy, relatively calm phase of her life.
"When it first started, I’d check the locks and stove a few times. As time went by, I started checking more and more things—the iron, the hair dryer, the window-screen locks—and I’d check them each dozens of times before leaving for work and before going to bed. At its worst, the checking and re-checking took three to four hours a day. It became difficult to socialize, because it was exhausting, physically and emotionally.”
OCD is sometimes called the doubting disease, and it’s easy to see why. “I would look at a gas burner and see it was off, but the second I looked away a flicker of doubt would enter my brain, and I’d think, Is it really off? Maybe I accidentally bumped it and turned it back on. I wouldn’t feel safe until I checked it again,” Coulter says.
“People with OCD have intrusive, upsetting thoughts that make them feel anxious. And they use their compulsions, whether it’s checking the stove or washing their hands, to relieve the anxiety — so the illness becomes self-perpetuating,” says Elna Yadin, PhD, director of the OCD Open Clinic at the University of Pennsylvania Center for the Treatment and Study of Anxiety. “Anxiety relief feels good, so that fuels the compulsive behavior, even though they realize that the behavior is either irrational or excessive.”
How to get better
Cavanaugh, who believes she’s had OCD her whole life, didn’t improve with SSRIs. But she’s found some relief with a combination of three medications and an intensive in-patient treatment program at McLean Hospital, one of two in the country. There she did a form of cognitive behavior therapy known as exposure and response prevention (ERP). Patients list all of the triggers that produce fears and anxieties and then, starting with the least distressing, tackle them one at a time in order to break the stranglehold their fear and anxiety have on them.
“Every time you do something that causes distress and face your discomfort without performing a ritual, the easier it gets,” Yadin says. “The goal is habituation—getting used to the thoughts so they lose their power to cause anxiety.”
Exposure and response prevention (ERP) seems to really work: In January 2008, researchers from the University of California, Los Angeles, reported that just four weeks of intensive ERP not only improved OCD symptoms and daily functioning but also caused changes in the brain that correlated with symptom improvement. Results are similar with drug treatment (medication causes some brain changes, too), but doctors say the effects of therapy are more long-lasting. “To get the best response, most doctors recommend a combination of drugs and therapy,” Dr. Saxena says.
Pittsburgh’s Hilary Zurbuch, who has a master’s degree in counseling and is currently working as a therapist, has tried a number of medications and completed an 18-month ERP program. Zurbuch says that she is “virtually symptom-free” now. “I can actually think about bad things happening to my family without performing a ritual afterward. It has been a process of learning to live with the discomfort.”
ERP has been life-changing for Anne Coulter, too. She did an intensive, three-week outpatient treatment. “The therapist would come to my house and have me turn on the stove, then turn it off and leave the room,” Coulter says. “It doesn’t sound traumatic, but for me it was. After three weeks, though, I saw a dramatic improvement.” Coulter no longer has to take medication, and her symptoms are mild and sporadic — “more like an allergy than a full-blown illness. I sometimes have a flare-up, but I can usually get myself back on track thanks to what I learned in therapy. Therapy gave me my life back. It helped me learn to not only live with doubt but to live happily with it.”