The washington diplomat

The Washington Diplomat - February 2003
OCD Causes Many To Suffer - by Carolyn Cosmos
A successful, middle-age tax attorney with a large family is having a meal at a restaurant in downtown Washing-
ton. Fearful that he might have put poison in the saltshakers on each table, he finds himself surreptitiously col-
lecting and hiding them, tormented by the thought that he might injure someone.
These fears arise whenever he eats out, and he has even stolen saltshakers in the past, putting them in his brief-case to protect other restaurant patrons. Deeply shamed by behaviors he realizes are irrational, and afraid ofalarming or disgracing his family, he suffers in silence. He has never told anyone about this problem.
A young Maryland mother admired for her tireless community work becomes convinced that she might molesther two little girls, although she has no actual interest in doing so. Heterosexual, happily married and deeply reli-gious, she becomes so afraid to even touch the young children who need her that her husband must care forthem. She repeatedly confesses to her parish priest and priests in other parishes as well, desperately travelingfrom church to church seeking relief but unable to find it.
A teenage boy who lives in Northern Virginia, a soccer player with a knack for math who pushes himself to get top grades, is driving along a highway. Feeling his car go over a bump, he asks himself, "Was that a bump? Or a body? Did I run over someone?" He drives back to the spot to check.
The next day he calls the local police station and scans newspapers to see if anyone in that area had been hit by a car. In the following weeks, he drives back to that spot in the road to check it out again and again and again. Re-alizing his irrational panic, the boy's occasional pot smoking with friends steadily increases as he tries to blot out his terror that he will wind up in a mental hospital instead of an Ivy League college.
All of these examples are fictional composites based on the clinical experiences of Dr. Gerald Nestadt, professorof psychiatry and behavioral sciences at The Johns Hopkins University School of Medicine in Baltimore, Md. Al-though they do not depict actual individuals, they do illustrate the kinds of troubling obsessions and compul-sions that haunt people suffering from obsessive compulsive disorder.
The typical person with obsessive compulsive disorder, or OCD, thinks they're crazy. They're so ashamed and embarrassed by it they may even see a counselor without mentioning it. That's very typical, said Nestadt, who also serves as the director of the Hopkins OCD clinic.
Nestadt said that OCD is a highly treatable anxiety disorder and brain disease that typically appears in the teenyears or early adulthood, although children can also develop OCD. People with OCD have intrusive, unwanted,unpleasant, and repeated thoughts and impulses that cause them immense distress, such as obsessive worriesabout dirt.
They may be afraid they'll kill their mother or sleep with their sister or spread germs. They may be scared to touch a toilet with their bare hands, may hoard objects until they pile up apartment rooms with trash, or they might suffer from repeated compulsions to check light switches they've turned off or appliances theyíve un-plugged. And, in the classic case of OCD, they may suffer from the need to repeatedly wash their hands some-times hundreds of times a day until their skin is cracked and raw.
How common is it to suffer from this disease? A cross-national study suggests that between 1 percent and 3 per- cent of the planet's population suffers from OCD, said Nestadt. He noted that the rate in the United States and Canada is 2.3 percent in each country.
A Plural Problem
Tom Corboy, director of the OCD Center of Los Angeles, emphasizes that there are different kinds of OCD and a wide range of related anxiety disorders, although experts strongly disagree on how to classify all the variations.
In addition to the "classic" OCD that involves, say, compulsive hand washing or repeated lock checking, Corboy said there is also obsessional OCD in which, for instance, a person may harbor such a persistent fear of stabbing someone that they won't allow scissors or knives in the house, or they'll lock all their scissors away.
There is also a loosely related cluster of disorders sometimes labeled "obsessive compulsive spectrum disorders", although one expert interviewed for this story, Jeffrey Schwartz, described the spectrum category as "nonsense".
This spectrum can include hypochondria, where people are consumed with worries about being sick when theyactually are not; trichotillomania, or compulsive hair pulling; a separate skin-picking disorder that resembles hairpulling; and body dysmorphic disorder, in which people worry excessively about their appearance and may haverepeated cosmetic surgeries to correct perceived flaws.
Some OCD experts also classify compulsive gambling, compulsive shopping and compulsive sex with the OC spectrum disorders. "I'm not one of them", Corboy said. "I would say, instead, they're an impulse control prob-lem". With cybersex or shoplifting, he said, people are getting pleasure. In contrast, people with OCD don't find any sort of pleasure in their problems.
Adding to OCD's kin list, last December a Kansas City research team linked Prader Willi syndrome, in which people have a short stature, are obese and may be intellectually disabled, to OCD, finding that Prader Willi eating compulsions are caused by genes related to OCD. The work, reported by AScribe Newswire, is being done at the University of Kansas School of Medicine and Children's Mercy Hospital.
And finally, extreme perfectionists have their own niche completely separate from the "classic" form of OCD: It's called obsessive compulsive personality disorder, or OCPD.
"With OCD", Corboy said, "a person will have thoughts that appear to be separate from who they are". They will have a hand-washing compulsion, for example, and typically have good insight into it, saying to themselves, In contrast, he said, with obsessive compulsive personality disorder, people may be extreme perfectionists but in-stead of thinking, "This is crazy", they think, "Everybody should be this way". Corboy added that with OCPD, "the thoughts don't cause them distress because they think the rest of the world is doing it wrong".
According to the American Psychiatric Associationís Diagnostic and Statistical Manual of Mental Disorders (DSM IV), OCPD is "a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency". Such people may be preoccupied with details, lists and schedules to the point where they can't see the forest for the trees, becoming so bogged down in detail and so focused on perfection that they are unable to complete projects.
OCPD sufferers may insist that others submit to their perfectionist ways. "Unlike people with OCD, they're not tor tured", Corboy said. "With OCPD, it's their families who are tortured". They may be thinking, "Even though it's causing my spouse to divorce me, it's a good thing".
Corboy emphasized that both types of disorders can be highly functional. "Bosses love them. The OCPD is the guy who's working 16 hours a day to get everything just right. The woman with OCD is tortured by her thoughts but can be very successful. I have OCD clients who are successful CEOs".
Corboy noted that hoarding disorder, in which people have difficulty throwing things out and may live in rooms piled high with trash, can be part of OCD proper, or part of the OCPD personality disorder, or it can occur inde-pendently.
"You will see it suddenly appear in seniors. Somebody is 80 years old and there's nothing else wrong with them, and they'll suddenly start hoarding", Corboy said. "Or people will hoard just animals. They'll have 250 cats in the house, 50 of them dead and the rest starving. But they're not exhibiting other problem behaviors".
Body Dysmorphic Disorder
Body Dysmorphic Disorder (BDD) is not nitpicking or fussing about one's appearance. It's a serious disorder that puts people who suffer from it at risk for committing suicide. For example, 30 percent of the people in one BDD study group reported at least one attempt at taking their own lives.
Diagnosing the disorder can be difficult because "sufferers often keep their symptoms secret due to embarrass-ment and shame", wrote Dr. Katharine A. Phillips and Dr. Ralph S. Albertini in an article for World College Health.
Phillips, author of "The Broken Mirror", a book on the subject, is director of the Body Dysmorphic Disorder and Body Image Program and a professor of psychiatry and human behavior at the Brown University Medical School in Rhode Island.
Phillips and Albertini said that people with BDD consider minor or nearly invisible physical flaws to be notice-able and ugly, and will obsess about their appearance at least one hour a day, but more typically several hours.
Their daily functioning can be impaired. Others may repeatedly turn to plastic surgery to correct their imaginedor exaggerated bodily flaws.
Although BDD has been linked to depression, the OCD Center of Los Angeles notes, "BDD has obsessive-compul-sive features that are quite similar to those of OCD. In fact, one recent study found that 24 percent of those with BDD also had OCD".
Pulling Hairs
ìMost people with trichotillomania think, "I must be crazy", said Dr. Angela Neal-Barnett, an associate professor of psychology at Kent State University in Ohio and director of a program for research into anxiety disorders among African Americans. People with "trich" have seemingly irresistible urges to pull out the hairs on their head, sometimes to the point of stripping themselves bald. They may also, in some instances, pull out their eye-brows or eyelashes.
Noting that people of color who have trichotillomania and OCD are underrepresented in research studies and areless often seen at clinics than their white counterparts, Neal-Barnett has created a groundbreaking outreach pro- gram embedded in the idea that all mental health outreach needs to be culturally appropriate, and may work bestif clinicians go out to communities rather than wait for patients to come to them.
Neal-Barnett is finding, for example, that African-American women with trichotillomania can be found in many beauty shops, and she's developed a video that educates hairdressers and their customers about the disorder.
The disorder is defined in various ways. The Trichotillomania Learning Center in Santa Cruz, Calif., following the DSM, categorizes it as an "impulse control" problem, but others in the field also note that it responds to the same treatments as those used for OCD.
What Causes OCD?
When it comes to the causes of OCD and related disorders, most experts believe that genetic variables are in-volved along with learning factors, including the way people have been raised. In addition, according to Corboy, "Some studies have found a link between rapid-onset OCD, especially in children, and strep infection", although "not everyone with OCD has had strep and not everyone who gets strep develops OCD".
The Johns Hopkins University has been exploring the OCD-genetic factor through a family genetics study since1995, said Dr. Jack Samuels, assistant professor at The Johns Hopkins University School of Medicine and co-inves-tigator of the OCD family study.
"The first part of our study was designed to see if OCD runs in families. It does," Samuels said. "Twelve percent of the first-degree relatives of people with OCD, that is their parents, children or [brothers and sisters], had OCD disorders", he reported, compared to the typical 2 percent of close relatives who have OCD among people who donít have the disease.
Samuels added that the close relatives of people who did have OCD also tended to have more panic attacks and depression than the relatives of people free of the disease, as well as more tics and disorders, such as hair pulling. "There may be a dominant gene involved", he said, noting that researchers hope to identify that gene in the sec-ond phase of the study.
One exciting find so far, Samuels said, is that the younger the age of onset of OCD, the more likely it is that a rela-tive will have the disorder too. This suggests that the younger a person is when the disorder first appears, thestronger the genetic component. Like others involved in genetic studies of human diseases, the researchers hopetheir work will eventually lead to new and improved treatments.
"We are interested in recruiting more families for the study", Samuels saidóthat is, recruiting families in which two or more relatives may have OCD. Participants do not need to be U.S. citizens and all information is kept con-fidential.
How OCD Is Treated
Experts agree that not only are OCD and many of its related disorders highly treatable, one of these experts, Dr. Jeffrey M. Schwartz, has outlined a popular self-help program for OCD in his book "Brain Lock: Free Yourself from Obsessive-Compulsive Behavior".
Through self-help alone, using the techniques discussed in the book, "people with motivation can get relief from their OCD symptoms in weeks", Schwartz told The Washington Diplomat.
"Some of my patients swear by it"î said another OCD clinician, speaking of the self-help book. Others find it less useful".
Said Schwartz, "We teach people that their urges are caused by false brain messages they don't need to listen to. They're the victim of bad brain circuits". If they follow the steps in his book, which are based on standard thera-pies now used in the treatment of OCD, Schwartz said, "People can activate more healthy brain circuits. They can change their brains".
Brain scans of patients done before and after OCD treatment bear his assertions out, revealing physical changesin the brains of patients who have undergone therapy alone.
Corboy, Schwartz, Nestadt and other OCD specialists interviewed for this article all agree that the best treatment for the disorder is a type of cognitive behavioral therapy called "exposure and response prevention", or ERP, sometimes used in combination with medications, such as those used to treat depression, including Anafranil, Prozac or Paxil.
In ERP therapy, people with OCD are exposed to their obsessions, such as a fear of being a pedophile, while be-ing prevented, or preventing themselves, from following through with a compulsive response, such as avoiding schools. A therapist in this case might drive a client to a school parking lot and have them sit there for 15 min-utes.
Progress can appear relatively quickly, Corboy observed: "I tell my clients this is not 'Woody Allen therapy'. You're not lying on somebody's couch for 20 years. It typically takes once-a-week [therapy] for four to six months for the average person. There are more intensive programs for the most severe cases, but the treatment for the normal person with OCD is once a week, [with] in-between homework. All my clients go out with a list of as-signments".
"We have scientific evidence that cognitive behavioral therapy alone actually causes chemical changes in the brains of people with OCD", wrote Schwartz in his book "Brain Lock". "We have demonstrated that by changing your behavior, you can free yourself from brain lock, change your brain chemistry, and get relief from OCD's ter-rible symptoms".
Calling OCD a "devilish disorder" and a "living hell" that was once thought intractable, Schwartz, like many of his clinical colleagues, thinks that OCD is now one of the more treatable disorders in the mental health profession.
Carolyn Cosmos is a freelance writer in Washington, D.C.

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