Cats do not climb into washing machines. Nor do they take refuge in dishwashers, ovens, or refrigerators. The young chemistry graduate student knew this full well. Yet he was unable to turn on his washing machine before checking over and over again to make sure one of his pet cats had not wandered inside. He couldn’t take food out of his fridge without repeatedly opening and closing the door until he was convinced that a cat had not accidentally become trapped. Of course he knew that this behavior made no sense at all. Nevertheless, he was compelled by some inner force to check and recheck. Such is the bizarre nature of obsessive-compulsive disorder, or OCD.
Can you imagine a twelve year old having to touch a door-knob in his room exactly 375 times before being able to go outside, or a teenager doing sit-ups, unable to stop, sometimes screaming in pain, until he had completed a self-prescribed number? How about the lady who saw a cockroach run across the floor of a supermarket, and for the next fourteen years, washed all her groceries—as well as everything else she brought into the house—in an attempt to protect herself from germs? Or the man who scrubbed his hands as many as fifty times a day, unable to stop, even though they were inflamed and bleeding? What about the teenager who couldn’t help counting everything he came across: telephone poles, passengers in passing cars, letters on signs, or words in a sentence? These things are unimaginable— except, of course, to those suffering from OCD. Then they are very real—real enough to destroy lives.
First, a couple of definitions are in order. Obsessions are unwanted, unreasonable, intrusive thoughts that can poison virtually every waking moment. Fear of contamination by germs, fear of accidentally doing harm to others, and a fear that terrible things will happen if something is left undone are typical examples. Compulsions are rituals that are performed in some hapless attempt to gain relief from obsessive thoughts. A sixty-year-old man, for example, suddenly developed an obsession about garbage on the street, and became convinced that if he did not pick up every bit he encountered, some horrific calamity would befall him. He began to collect whatever he could in garbage bags, which he then stored in his house. He eventually lost his job because he was spending so much time picking up garbage that he never made it to work. This gentleman was intelligent, totally aware of the ridiculous nature of his activity, but was powerless to do anything about it. So was the sixty-five year old who spent some twenty-five years trying to sneak a peek at other men’s penises. He had no homosexual urges at all, but was obsessed by the thought that his life would be destroyed if he did not meet his daily quota. Sometimes he would have to drive from truck stop to truck stop, waiting in the bathroom, to try to glimpse a view. Relief came only when he met his quota. Then he would have to start all over again the next day.
These people are most assuredly not insane, but they are mentally ill. Often, they are very intelligent, which makes their torment even more difficult to accept. So then what causes roughly 2 percent of the population (more than suffer from Alzheimer’s disease) to be afflicted by this terrible condition? One thing is clear: it has nothing to do with any repressed memories, feelings of guilt, or overbearing parents. There are no subconscious mental conflicts involved. Lady Macbeth trying to wash away her guilt is not a model for OCD. No recorded case exists in medical literature of anyone having been “cured” of OCD through psychoanalysis. But there are numerous cases of victims who have been helped by behavioral and pharmaceutical intervention. The consensus now is that OCD is, like other physical ailments, caused by something having gone awry in the body’s complex chemistry.
What evidence is there for this? First of all, the condition is sometimes precipitated by physical injury. Blows to the head, epileptic seizure, and strokes have been known to trigger OCD. Swiss researchers report a fascinating case of a political journalist who had no particular interest in food until he suffered a brain hemorrhage. Following his recovery, he began to compulsively think about eating, and even switched careers to become a food columnist. This tweaked the researchers’ interest, and they began to assess patients who had presented with various brain lesions for what they now called “Gourmand syndrome,” the development of a sudden obsession with food. Over a three-year period, they uncovered thirty-six such patients, thirty-four of whom had lesions in the right anterior area of the brain. Even more interesting evidence comes from PET (positron emission tomography) studies of the brains of OCD patients. This technique measures brain activity and has confirmed that in OCD parts of the prefrontal cortex and parts of the basal ganglia, particularly the pecan-sized “caudate nucleus,” are overactive. When patients improve after treatment, this activity is reduced. The fact that medications that specifically increase serotonin levels in the brain help with OCD also suggests a chemical malfunction.
Then there is the case of the twenty-two year old who was so frustrated by his OCD that he attempted suicide. He shot himself in the head, but survived. Amazingly, along with part of his brain, his OCD also disappeared! Obviously, this is not recommended treatment. What, then, can people who suffer from OCD do? I developed an interest in answering this question many, many years ago, when I first started teaching organic chemistry. I’ll never forget my first class.
I was young, fresh out of graduate school, and ready to wow the class with a lecture I had spent hours and hours preparing. After a brief introduction, I turned around to write my name and office number on the board. That’s when it happened. I heard a loud bark! I hadn’t seen a dog in the classroom, so I couldn’t imagine where the sound had come from. Looking around revealed nothing unusual. When I turned to face the board again, the barking started up once more. This time it was followed by a loud string of obscenities! Ruling out the possibility of foulmouthed canines, I scanned the classroom more carefully. My eyes came to rest on a student sitting in the back with his hands clamped over his mouth, in an obvious state of distress. Then the hands suddenly dropped, and he let out a horrific bark, followed by, to my great astonishment, an obscene gesture with his finger. And that was how I was introduced to the intricacies of Tourette’s syndrome, one of the most fascinating of all mental diseases.
Up to that fateful day back in 1973, I had never heard of the condition first described by French neurologist Gilles de la Tourette in 1884. But my ignorance didn’t last very long. Numerous conversations with my student revealed that he was highly intelligent, but tormented by the uncontrollable urge to grunt and bark (vocal tics), grimace (motor tics), scream socially unacceptable phrases (coprolalia), and make obscene gestures (copropraxia). Something was obviously askew in his brain; some chemistry was going wrong. Once we had explained this curious affliction to the class, his symptoms improved. I suppose that the stress of trying to hide the condition that first day probably brought on the extreme manifestations, and scared me half to death.
Eventually I learned that about half of all Tourette’s patients also suffer from obsessive-compulsive disorder (OCD). Unfortunately, my poor student fell into this category. He had difficulty finishing exams because he could not go on to the next question until he was convinced that he had gotten the previous one perfect. Pencils and pens on his desk had to be lined up in order of increasing size, and any disruption of this arrangement would bring on signs of terrible internal turmoil. This really stirred my interest, because I also had a friend who was compulsive about keeping things “just right.” I had never considered this to be a disease, and I must even admit to a little mischievous enjoyment found in watching him scramble after I revealed I had rearranged something in his house. Thanks to the episode with my student, though, I now realized that OCD was no laughing matter.
Tourette’s and OCD are related in the sense that both are due to some faulty brain chemistry, and both have a genetic component. The chemical faults, however, are not the same, and a person can suffer from either condition without being afflicted by the other. Some of the symptoms of Tourette’s are similar to those of schizophrenia, a mental illness partly attributed to high levels of the neurotransmitter dopamine. That’s why medications that block dopamine activity were the first ones tested in the treatment of Tourette’s syndrome. Haloperidol (Haldol) was adept at reducing the symptoms, but caused Parkinson’s-like side effects. Excessive norepinephrine activity has also been associated with tics, and clonidine (Catapres), which controls norepinephrine levels, has proven to be useful in Tourette’s, as well as in the treatment of OCD.
Depression is a common side effect of obsessive-compulsive disorder, and its treatment with clomipramine (Anafranil), an antidepressant, resulted in the first truly effective drug against OCD. Physicians noticed OCD symptoms were alleviated in patients treated with clomipramine. Since this drug raises serotonin levels in the blood, the search was on for other medications that would do this even more effectively. The selective serotonin reuptake inhibitors (SSRIS), like fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil), fit the bill, and have become the therapy of choice for OCD.
In rare cases, in children, OCD can be triggered by a streptococcal infection. White blood cells produce antibodies to fight off such an infection, but they may sometimes mistakenly attack and destroy cells in the caudate nucleus, an area of the brain known to function improperly in OCD patients. In such cases, passing the blood through a machine that filters out the rogue antibodies can afford relief from OCD, as can treatment with antibiotics. The best hope, though, to help people tortured by OCD lies in behavioral therapy, whereby they have to confront their fears. A person terrified of germs is encouraged to handle some object—money, for example—that obviously harbors them. They are then asked to resist the urge to wash their hands immediately. At first, it’s a real struggle, but eventually, by increasing the time until they give in to the compulsion to wash, they learn that nothing terrible happens. Usually a combination of behavioral and drug therapy makes OCD manageable, but a total “cure” is rarely achieved. Patients commonly see several doctors before a proper diagnosis is made, and take an average of seventeen years from the onset of symptoms to find appropriate treatment.
My student was eventually treated with haloperidol and clomipramine and went on to a successful career as an engineer, although he still has the occasional urge to bark during meetings. But, having learned from the experience in my class, he now informs his colleagues of his condition so that they are not shocked by the sounds or obscenities.