Obsessive Compulsive Disorder: Strange Manners Still Fox Researchers

Part 2

It is with diseases of the mind as with diseases of the body, we are half dead before we understand our disorder, and half cured when we do.

–Colton

How does one treat a patient who suffers from complications associated with obsessive compulsive disorder (OCD). This article throws light on some latest therapeutic method.

There are behavioural psychotherapies that may work for some patients with OCD, but this is a very hard condition to treat. Almost all patients ultimately take some medication in addition to therapy.

No single treatment seems completely beneficial for this condition, not even long-term psychotherapy, behavioural psychotherapy or drug therapy. However, OCD has recently become the subject of intense scientific study and some good treatments are beginning to emerge. Consequently, the situation is substantially brighter now.

There are many psychological theories about the cause of this serious illness, but it is agreed that it is one of the most biological of all mental disorders. Patients with OCD may seem perfectly normal to the casual observer. They often have none of the odd behaviour or strange man­nerisms common to some psychotic or schizophrenic patients. But the obsessive compulsive patient is a prisoner to senseless thoughts and the need to repeat meaningless rituals. Sometimes he may become very depressed over his behaviour, though it is rare for patients with OCD to attempt suicide. The patient doesn’t actually believe his hands are so dirty as to warrant incessant washing. He often swears he will stop. But he cannot. Something—a brain abnormality, perhaps—forces him to have the obsessions and act out the compulsions over and over.

Psychiatric drugs and OCD

Almost every psychiatric drug known has been used to treat OCD, including Tricyclic antidepressants, SSRI antidepressants, MAIOs (Monoamine Oxidase Inhibitor), antipsychotic drugs, amphetamines, clonidine, and tranquillizers. Electroshock treatment is reported to work sometimes, but these treatments work only in exceptional cases.

Two kinds of drugs are now known to have specific anti-obsessive- compulsive properties: the Tricyclic antidepressant Anafranil and the Selective Serotonin Reuptake Inhibitors (SSRIs) Luvox, Prozac, Paxil and Zoloft. Since the primary FDA approval in the United States was given for Anafranil and Luvox for the treatment of OCD, they are included here. Paxil, Prozac and Zoloft have also been approved for treatment of depression. However, SSRI drugs are often regarded as equally effective. Anafranil may be slightly more effective for OCD than the SSRIs, but also has more side effects.

The brain’s billions of nerve cells communicate with each other largely via neurotransmitters. Typically, a nerve cell, or neuron, will manufacture a neurotransmitter and then excrete it into the gap, or synapse, between it and an adjoining nerve cell. When the neurotrans­mitter makes contact with a receptor on the surface of the second nerve cell, the ‘message’ or nerve impulse is then transmitted from one nerve cell to the next. Millions of such messages are sent every second in the human brain.

So far, several dozen of these chemical messengers, or neurotrans­mitters, have been identified. Several of these neurotransmitters— norepinephrine, dopamine and serotonin—seem to play major roles in governing a person’s mood, and all the antidepressants (the MAOIs, tricyclics and SSRIs) work by boosting brain levels of one or more of the chemical.

Serotonin: A ray of hope

Among the mood-affecting neurotransmitters, serotonin seems to be especially important. It’s the primary neurotransmitter that drug de­signers have targeted over the past 10 years in trying to synthesize antidepressant drugs—an effort that has led to the development of prozac and the other SSRIs now in the market.

All the SSRIs are based on the principle that depression often results from abnormally low levels of serotonin in the gaps, or synapses, between the nerve cells. The SSRIs boost synoptic levels of serotonin, and the increase serves to rev up communication among nerve cells and eventually results in improved mood.

The SSRIs increase serotonin levels between the cells by capitalizing on the fact that the nerve cells, or neurons, are frugal when it comes to their neurotransmitters and do their best to recycle them. Shortly after neuron A communicates with adjacent neuron B by releasing a dose of serotonin molecules into the synapse between the two cells, neuron A will reabsorb these serotonin molecules through use of special recep­tors on its surface known as reuptake pumps. Prozac and all the other SSRIs somehow block these pumps so that serotonin cannot be reab­sorbed by neuron A. The result: reuptake of serotonin is selectively blocked, serotonin molecules accumulate in the synapses—and depres­sions are lifted.

Primary treatment

The SSRIs have now become the primary treatment for OCD, along with the tricyclic clomipramine. Serotonin has been studied in OCD and is found to have a role, as it does in aggression, anxiety, learning, social dominance, impulsivity, and suicide. Clomipramine has a-potent serotonin effect, and is more effective against OCD than is desipra- mine, which is a norepinephrine-specific tricyclic. All the SSRIs have proved effective in treating OCD and, combined with behaviour thera­py, offer those suffering from this painful and debilitating condition real hope of spending less time obsessively checking, hoarding, and washing, and more time with family, friends, and in meaningful worL This combination therapy helps most people get better, but does not cure them completely Because OCD is a chronic illness that waxes and wanes, SSRI treatment must be long-term. Symptomatic improvement may continue steadily for months.

In 1991, a scientist in the United States hypothesized that patients with trichotillomania would exhibit the same brain imaging as those with OCD. At rest, these patients exhibited a different brain pattern. Yet when these patients were treated with the antiobsessive antidepressant Anafranil, there was decreased activity in the cingulate region of the frontal lobes, which has also been found with successful treatment of OCD with antiobsessive antidepressants.

Like most forms of psychiatric illness, part of effective treatment for OCD often involves medication. At this writing, there are eight ‘an­tiobsessive medications’ and more on the way. The current medications that have shown effectiveness with OCD are Anafranil (clomi­pramine), Prozac (fluxetine), Zoloft (sertraline), paxil (paroxetine), Effexor (venalafaxine), and Luvox (fluvoxamine). These medicines have provided many patients with profound relief from OCD symp­toms.

In addition, behaviour therapy is often helpful. The patient is gradu­ally exposed to situations most likely to bring out the rituals and habits. The therapist teaches the patient thought-stopping techniques and strongly encourages him or her to face his or her worst fear (for example, by persuading a patient with a fear of dirt or contamination to play in the mud).

Hypochondriasis: A tough OCD

However, of all the manifestations of OCD there is perhaps nothing more agonising and difficult to manage than hypochondriasis, or more familiarly, hypochondria, which is a persistent preoccupation with the possibility of having one are more serious progressive physical illnesses such as cancer. Patients show persistent concern with their health, and commonplace sensations such as ‘missed’ heartbeats generate severe anxiety. Reassurance that there is no underlying organic disease fails to alleviate the condition.

Hypochondriasis may on the surface appear to be merely an annoy­ing manifestation of a nervous temperament. But the patient who has this condition usually suffers the agonies of hell in his own mind. He has an obsessive fear that he is suffering from some form of cancer and on the other, he lacks the courage to go in for investigation, which alone can set his mind at rest. He finds himself in a situation in which he is totally isolated with his own fears. Since his range of suspicion and fear can cover the entire spectrum of the human physiological system, it becomes difficult for the normal physician to constantly keep reassur­ing him that he has no serious ailment without carrying out a battery of tests for which again the patient is unwilling to subject himself.

Thus, in all medical therapy hypochondriasis is perhaps the single most difficult condition to manage or treat from the point of view of the patient, the members of his family and also the physician, whose task is unenviable. These features are quite common in depressed patients and it can be difficult to determine whether what appears to be hypochon­driasis is really a symptom of depression. Hypochondriacal patients have been found to be almost ten times more likely to suffer from a major depression. In some cultures there is a higher tendency to refer to bodily, as distinct from psychological, ‘pain’. Hypochondriasis is considered by some to be simply the somatization of depression.

While somatization due to the stigma and shame that can attach to mental illness has been emphasized in non-western societies, its pres­ence in western societies may be grossly under-reported. In one study of 1,000 patients visiting a medical diagnostic clinic, no organic medical illness could be detected in over two-thirds of them. So while physical distress is a main reason for going to a general practitioner, the most common diagnosis is the absence of organic disorder. But one must recognize that it can be very difficult to tell the difference between symptoms that are psychosomatic caused by organic illness. It is impor­tant to determine with certainly whether the physical symptoms are concealing a depressive illness or whether they are ‘real’, that is, due to organic pathology.

It is curious that conversion disorders, made so famous by Freud, in which an emotional conflict was converted into, for example, blind­ness, deafness or paralysis, seem nowadays to be very rare. One possibility is that many of the cases Freud reported were indeed due to a physical disorder.

A long way to go

Medicine has still a long way to go to help these unfortunate individuals though there has been a radical change of attitude towards their prob­lem. As against the old theories that most mental problems (excluding psychoses) were largely the result of the impact of environmental factors on a person’s early life, there is now a realization that the medical changes taking place in the brains of such individuals have to be treated for deficiency or over-activity, as the case may be, by specific drugs such as the SSRIs. In this connection, a part of the brain known as the Cingulate Gyrus has acquired great importance of late.

Thus, for the first time the role of the Cingulate Gyrus and our ability to modulate Serotonin have become front-line weapons in the medical arsenal for overcoming problems such as OCD.