Obsessive Compulsive Disorder: Cingulate Gyrus may Hold the Key

Part 3

A weak mind is like a microscope, which magnifies trifling things, but cannot receive great ones.

– Chesterfield

The importance of Serotonin is beginning to be realized as even doctors are seeking nutritional intervention to regulate Serotonin levels.

Traversing longitudinally through the deep central aspects of the frontal lobes is the cingulate gyrus. It’s the part of the brain that allows you to shift your attention from one thing to another, to move from one idea to another, to see the options in life. Feelings of safety and security have also been attributed to this part of the brain. Experience has shown that the term that best relates to this part of the brain is Cognitive Flexibility.

Cognitive flexibility defines a person’s ability to go with the flow, adapt to change and deal successfully with new problems. Many situations in life demand cognitive flexibility. For example, when you start a new job, you need to learn a new system of doing things. Even if you did something another way at a previous job, learning how to shift to please a new boss or adapt to a new system is critical to job success. Junior high school students need cognitive flexibility in order to be successful in school. In seventh grade, many students begin to get used to having various teachers throughout the day. It is necessary to adapt to the teaching styles of different teachers. Flexibility is also important in. friendships. What works in a friendship with one person may not be effective with another.

Effectively managing change and transitions is an essential ingredient in personal, interpersonal and professional growth. The cingulate system can be of great help or hindrance to this process. When it is working properly, we are able to roll along easily with the various developments of the day; when it is impaired or overactive, cognitive flexibility is diminished.

Along with shifting attention, we have seen that cooperation is also influenced by this part of the brain. When the cingulate works effectively it’s easy to shift into cooperative modes of behaviour. People with cingulate problems have difficulty in shifting attention and get stuck in ineffective behaviour patterns.

The cingulate system has also been implicated (along with the other aspects of the PFC) in ‘future-oriented thinking’, such as planning and goal-setting. When this part of the brain works well, it is easier to plan and set reasonable goals. On the negative side, difficulties in this part of the brain can cause a person to perceive fearful situations where there are non-predict negative events and feel unsafe in the world.

Seeing options is crucial to adaptable behaviour. Adaptable physicians readily utilize new ideas and technology (after a scientific basis is developed), and they are open to giving their patients the latest information on what is new and exciting. Physicians who have cingulate problems tend to be rigid, do things the way they have always been done, and be autocratic (‘Do it my way if you want me to treat you’). Being able to see options and new ideas protects against stagnation, depression and hostile behaviour.

When the cingulate system is abnormal, people have a tendency to get stuck on things, locked into things, to rethink the same thought over and over. They may become worriers and continually obsess about the same thought. They may hold on to hurts or grudges from the past, unable to let them go. They may also get stuck on negative behaviours or develop compulsions such as hand-washing or excessively checking locks.

One patient who had difficulties in this part of the brain described this phenomenon ‘like being on a rat’s exercise wheel, where the thoughts just go over and over and over’. Another patient opined: ‘It’s like having a reset button that is always on. Even though I don’t want to have the thought anymore, it just keeps coming back.’

The clinical problems associated with the cingulate will be discussed shortly. There are also a number of ‘subclinical patterns’ associated with abnormalities in this part of the brain. Subclinical problems are those that don’t cause the dysfunction of a full-fledged disorder, but can none the less erode our quality of life. Worrying, holding on to hurts from the past, cognitive inflexibility, and rigidity may not send you to the therapist, but they can make your life unnecessarily gloomy.

Biological pattern

Existing research in the past few years has shown a biological pattern associated with OCD, Brain SPECT (Single Photon Emission Computerized Tomography) studies have shown increased blood flow in the cingulate system, along with increased activity in the basal ganglia (often the anxiety component of the problem).

SPECT is a sophisticated nuclear medicine study that looks directly at cerebral blood flow and indirectly at brain activity. SPECT studies show which parts of the brain are activated when we laugh, sing, cry, visualize or perform other functions. These studies help in diagnosis of cancer, head trauma, dementia, mood disorders, strokes seizures as well as several other conditions.

Like most forms of psychiatric illness, part of effective treatment for OCD often involves medication. At the time of writing this, there are eight ‘antiobsessive medications’ and more on the way. In addition to behaviour therapy the current medications that have shown effectiveness with OCD are Anafranil (clomipramine), Prozac (fluoxetine), Effexor (venalafaxine), Serzone (nefazodone), Remeron (mirtazapine) and Luvox (fluvoxamine). These medicines have provided many patients with profound relief from OCD symptoms.

Medications are often very helpful in the cingulate part of the brain, especially those medications that modulate the neurotransmitter serotonin. Medications that increase serotonin in the brain are termed serotonergic. These include Prozac, Zoloft, Paxil, Anafranil, Effexor, Remeron, Serzone, Desyrel and Luvox.

Several research studies have shown that when these medications are effective, they normalize activity in the cingulate system. Clinically, these medications decrease a patient’s repetitive thoughts and compulsive behaviour, and relax people who have a tendency to be frozen by their inability to see options. When these medications work, they often have a dramatic effect on thoughts and behaviours.

Medications don’t work all the time, and sometimes they have side effects that can be annoying and even disturbing. Yet, serotonergic medications are some of the new and most effective weapons in the arsenal against emotional pain and suffering. They have helped millions of people lead normal lives.

In addition, Saint-John’s-Wort, a natural herbal treatment, can also be very helpful in raising Serotonin levels and calming the cingulate part of the brain. Saint-John’s-Wort has been studied head to head with several antidepressants and found to be just as effective and with few side effects.

It has been used for many years in Germany, where it is prescribed seven times more often than Prozac. The usual dose of Saint-John’s-Wort is 300 mg (containing 0.3 per cent hypericin) three times a day. Saint-John’s-Wort seems to be a very helpful treatment.

Low serotonin levels and increased cingulate activity are often associated with worrying, moodiness, emotional rigidity and irritability. There are two ways that food can increase serotonin levels. Foods high in carbohydrate, such as pastas, potatoes, bread, pastries, pretzels and popcorn, increase L-tryptophan levels (the natural amino acid building block for Serotonin) in the blood, resulting in more L-tryptophan being available to enter the brain, where it is converted to serotonin. The calming effect of serotonin can often be felt in thirty minutes or less by eating these foods.

Cerebral serotonin levels can also be raised by eating foods rich in tryptophan, such as chicken, turkey, salmon, beef, peanut, butter, eggs, green peas, potatoes and milk.

Many individuals unknowingly trigger cognitive inflexibility or mood problems by eating diets that are low in L-tryptophan. For example, the high-protein, low-carbohydrate diets that are recommended for low-dopamine states (related to prefrontal cortex under activity) often make cingulate problems worse. L-tryptophan is a relatively small amino acid. When you eat a high-protein diet, the larger amino acids compete more successfully to get into the brain, causing lower levels of brain serotonin and more negative emotional reactive- ness (the role of L-tryptophan is still considered controversial and does not still have the therapeutic credibility of say St. John’s Wort).

Nutritional supplements of L-tryptophan can also be very helpful. L- tryptophan was taken off the market a number of years ago because one contaminated batch, from one manufacturer, caused a rare muscle disease and a number of deaths. The L-tryptophan actually had nothing to do with the deaths. L-tryptophan is a naturally occurring amino acid found in milk, meat and eggs. Many patients have found it very helpful for improving sleeps, decreasing aggressiveness and improving mood control.

In addition, it does not have side effects, which gives it an advantage over antidepressants. L-tryptophan was recently reapproved by the United State’s Food and Drug Administration. Doctors recommend L- tryptophan in doses of 1,000-3,000 mg to be taken at bedtime.

There have also been some recent studies with inositol, from the Vitamin B family. If given a dose of 12 to 20 mg a day, it has been shown to decrease moodiness, depression and problems of over-focus. To sum up, obsessive compulsive neuroses (particularly hypochondriasis) remain one of the biggest challenges of modern medicine. These patients remain in that twilight zone between diseases causing mortality and disorders that cause agony and mental hardship to themselves as well as to those dealing with them.

In terms of quality of life lost, the loss is incalculable for in the absence of such a malady, patients who are essentially normal people would have given off the best years of their lives to society and to themselves.

Saddled, however, as they are with this strange affliction, which the medical community does not take seriously, untold misery is being caused to millions of people. It is rather ironical that even men trained in medicine, who should be the first to recognize the suffering being experienced by these people, contemptuously brush it aside as an eccentric aspect of a patient’s personality that need not be taken into account while treating him for physical ailments.

On the other hand, what a mature physician or surgeon should recognize and realize is that OCD is as painful to the victim, if not more, than a tumour or appendicitis or a pathological condition like infective hepatitis (to a person contracting that virus).

To laugh away the troubles of patients suffering from OCD or even to make them the butt of ridicule is not only uncalled for but shows an utter disregard for human dignity. The wise and experienced physician who encounters a patient suffering from OCD in addition to a physical ailment must in fact go out of the way to give him mental assurance and courage in the manner in which Hypocrites, the Father of Medicine, envisaged.

In a sense, the hypochondriac who imagines he has cancer of the stomach suffers more agony than a victim who is really afflicted with the disease; that being the case, physicians should perhaps gear their resources to reduce the mental agony of these patients rather than contemptuously drive them out from the consulting rooms and clinics all over the world.