The Mind and the Brain (7 page)

Dottie was a middle-aged wife and mother by the time she walked into my office at the Obsessive Compulsive Disorder (OCD) Research Group at UCLA Medical Center in Westwood, but she had been in the grip of obsessive-compulsive disorder since she was a little girl of five. Early on, it was the numbers 5 and 6 that paralyzed her with fear, she told me with some distress. I soon learned why: her obsession with the “magical” powers of numbers still consumed large portions of her life. If, while driving, Dottie glimpsed a license plate containing either a 5 or a 6, she felt compelled to pull over immediately and sit at the side of the road until a car with a “lucky” number in its license plate passed by. Without a lucky number to counteract the digits of doom, Dottie was convinced, something terrible would befall her mother. She would sometimes sit in the car for hours, waiting for the fates to bestow permission to hit the road again. When Dottie had a son of her own, her obsession shifted. Now it was eyes: Dottie was certain that if she made the
slightest misstep, her son would go blind. If she walked where someone with vision problems had walked, she would throw out her shoes; if she so much as heard the word
ophthalmologist
she would cringe in terror. As she spoke, I noticed the word
vision
written four times in the palm of her hand. Oh, that, she explained, eyes downcast: while she was watching television that afternoon, a terrifying thought about eyes had popped into her head. This was her way of exorcising it. If she hadn’t, there was no telling what might have befallen her son’s eyesight.

Obsessive-compulsive disorder is a neuropsychiatric disease marked by distressing, intrusive, unwanted thoughts (the obsession part) that trigger intense urges to perform ritualistic behaviors (the compulsion part). Together, obsessions and compulsions can quickly become all-consuming. In Dottie’s case, the obsessive thoughts centered first on her mother’s safety and then on her son’s eyesight; her compulsions were the suite of “magical” behaviors she engaged in to ward off disaster to the people she loved. The unremitting thoughts of OCD intrude and lay siege to the sufferer’s mind (
obsession
comes from the Latin verb that means “to besiege”), insisting that the doorframe you just brushed is contaminated with excrement, or that the bump in the road you just drove over was not an uneven patch of asphalt but a body sprawled on the pavement.

One of the most striking aspects of OCD urges is that, except in the most severe cases, they are what is called ego-dystonic: they seem apart from, and at odds with, one’s intrinsic sense of self. They seem to arise from a part of the mind that is not you, as if a hijacker were taking over your brain’s controls, or an impostor filling the rooms of your mind. Patients with obsessive-compulsive disorder experience an urge to wash their hands, for instance, while fully cognizant of the fact that their hands are not dirty. They ritualistically count the windows they pass, knowing full well—despite the contrary message from their gut—that failing to do so will not doom their child to immediate death. They return home to check
that the front door is locked so often as to render them unable to hold a job, even though part of their brain knows full well that it is securely locked. They count the steps from their car to the door of the office where they have a job interview, hoping and praying that the number will turn out to be a perfect square, a prime, a member of the Fibonacci sequence, or something else magical, since if it is not, they must do an about-face and return to the car to try again. They do this time and again, knowing that the interview time is fast approaching and that—oh, God, they’ve lost out on another job because of this crazy disease. OCD has a lifetime prevalence of 2 to 3 percent; in round numbers, it affects an estimated one person in forty, or more than 6 million Americans, typically striking in adolescence or early adulthood and showing no marked preference for males or females.

Excessive and ritualized hand-washing may be the best known of the OCD compulsions, but there are scores of others. They include alphabetizing the contents of a pantry, repeatedly checking to see whether a door is locked or an appliance is turned off, checking over and over to see whether you have harmed someone (peeking in on a sleeping child every minute, for instance), following rituals to ward off evil (like scrupulously avoiding sidewalk cracks), touching or tapping certain objects continuously, being unable to resist counting (totting up, every day, the traffic lights you pass en route home), or even excessively making lists. OCD can manifest itself as obsessions about order or symmetry, as expressed in an irresistible need to line up the silverware just so, or as an obsession about hoarding, as expressed in never throwing out old magazines and newspapers. Paradoxically, perhaps, giving in to the urge to wash or check or count or sort, which the patient does in the vain hope of making the dreadful feeling recede, backfires. An OCD compulsion does not dissipate like a scratched itch. Instead, giving in to the urge exacerbates the sense that something is wrong. It’s like chronic poison ivy of the mind: the more you scratch it, the worse it gets.

Someone with obsessive-compulsive disorder derives no joy from the actions she takes. This puts OCD in marked contrast to, for instance, compulsive gambling or compulsive shopping. Although both compulsive shoppers and compulsive gamblers lack the impulse control to resist another trip to the mall or another game of video poker, at least they find the irresistible activity, well, kind of fun. An OCD patient, in contrast, dreads the arrival of the obsessive thought and is ashamed and embarrassed by the compulsive behavior. She carries out behaviors whose grip she is desperate to escape, either because she hopes that doing so will prevent some imagined horror, or because resisting the impulse leaves her mind unbearably ridden with anxiety and tortured by insistent, intrusive urges. Since the obsessions cannot be silenced, the compulsions cannot be resisted. The sufferer feels like a marionette at the end of a string, manipulated and jerked around by a cruel puppeteer—her own brain.

Freud believed that OCD is a manifestation of deep emotional conflicts. As a result, patients who sought traditional psychiatric therapy for the illness were typically told that the rituals they performed or the thoughts they could not silence were rooted in sexual conflict and reflected, for instance, a repressed memory of childhood trauma. The content of the disease—why one patient can’t stop thinking that she left the coffee maker on, while another is beset by a compulsion to wash doorknobs—may indeed reflect the individual’s personal history. But as yet there is no biological explanation for why OCD expresses itself one way in one patient and a different way in another. Nor is it clear what the ultimate cause of obsessive-compulsive disorder is, though there is clearly a genetic contribution.

Until the mid-1960s, the psychiatric and psychological professions deemed OCD
treatment-intractable
: nothing could be done to release patients from its grip. “People didn’t know what to do with OCD,” says the clinical psychologist Michael Kozak, who spent nineteen years at MCP Hahnemann Hospital in Philadelphia study
ing the disease and its treatments. “They tried all sorts of things that didn’t work very well, from electroshock and psychosurgery to any available drug and classical talk therapy.” In the late 1960s and early 1970s, however, psychiatrists got a hand from serendipity: they noticed that when patients suffering from clinical depression were put on the tricyclic antidepressant clomipramine hydrochloride (Anafranil), some of them experienced relief from one or more of their OCD symptoms. Since clomipramine, among its many biochemical actions, strongly inhibits inactivation of the neurotransmitter serotonin (much as Prozac does), researchers suspected that amplifying the brain’s serotonin levels might alleviate OCD.

There was at least one problem with this approach, however. Though clearly effective, clomipramine is a “dirty” drug, one with numerous pharmacological actions; as a result, it is associated with many unpleasant side effects. This problem led to the development of so-called selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Paxil, Zoloft, Luvox, and Celexa, all of which specifically block the same mechanism that clomipramine acts on nonspecifically: the molecular pump that moves serotonin back into the neurons from which it was released, thus allowing more of the chemical to remain in the synapse. All of these SSRIs seem to be equally effective in treating OCD symptoms. For each of them, studies since the 1980s have shown, about 60 percent of patients respond at least somewhat, “and of those there’s about a 30 to 40 percent reduction in symptoms,” says Kozak. “So there’s something real going on with the drugs. But when about half of the people aren’t helped significantly and those who are helped are still left with 60 percent of their symptoms, we have a ways to go.”

At about the same time that researchers stumbled onto clomipramine for OCD, Victor Meyer, a psychologist at Middlesex Hospital in London, began to develop what would emerge as the first effective behavioral therapy for the disease. In 1966 he tried out, on five patients in an inpatient psychiatric ward, what would become the most widely used psychological treatment for the next
twenty-five years. Called exposure and response prevention (ERP), it consisted of exposing patients to the trigger that called forth obsessional thoughts and the compulsion to engage in a distress-relieving behavior. Meyer would tell a patient to leave her house, for instance, but prevent her from returning to check whether she had left the stove on. Or he would have her touch all the doorknobs in a public building but not allow her to wash her hands afterward. Or he would tell the patient to touch dried bird droppings but not allow her to wash (at least not right away). Meyer reported significant improvement in the patients he treated with exposure and response prevention. Edna Foa, who adopted the technique and added a detailed questionnaire to allow therapists to get at the patient’s so-called fear structure—the layers of emotions that underlie the obsessions—introduced it into the United States.

Typically, the first exposure during therapy uses a trigger that the patient has assigned a low score on a scale of “subjective units of distress,” or SUDs. The therapist (during in-office sessions) then prevents the patient from responding as he usually does—dashing to a sink to wash, for instance.
Prevents
can mean many things, from gentle coercion to physical restraint of the patient; from carefully explaining that if the patient complies he is likely to get better, to turning off the water in the bathroom of his room in a mental hospital. Exposures are also conducted at home; the patient works at stopping himself from acting on his compulsive urges. The patient, needless to say, can become extremely anxious during this phase, which often lasts an hour or more. Ideally, however, as therapy continues, he begins to master his responses to triggers further up the distress scale, the anxiety ignited by the triggers lessens, and he gains control of his thoughts and actions.

Controversy swirls around exposure and response prevention therapy, however. The most common claim for the treatment is that three out of four patients who complete therapy do well, experiencing a 65 percent reduction in their OCD symptoms. But that little phrase “who complete” hides a land mine. “The trouble is, a lot of
people won’t do it at all, they’re so afraid to confront their obsessions and not be allowed to carry out their compulsions,” says Kozak. During his work with Edna Foa in Philadelphia, where they developed one of the best programs in the United States, some 25 percent of patients refused to undergo a single session once they learned what was involved. With less adept clinicians, refusal rates can run even higher. Some clinicians manipulate their dropout rates by fiddling with the entry criteria: by doing a little exposure and response prevention and rejecting patients who can’t take it, researchers make their results look better. Even then, 10 to 30 percent of patients who agree to start therapy drop out. And not every clinician practicing exposure and response prevention has done it well, or wisely. “There have been quite some mistakes, with therapists abusing the method or going faster than patients would have liked,” says Dr. Iver Hand of the University of Hamburg in Germany, a pioneer in the field who developed a variant of ERP. “It is easy for a badly-trained therapist to abuse the method.” Compared to drugs, behavioral therapy seemed to produce better results for patients who could tolerate it. But the hidden statistics made it clear: for millions of OCD patients, exposure and response prevention was not the answer.

This was the state of play when I entered the field in the mid-1980s. It wasn’t so much psychology, or even physiology, that attracted me to the study of obsessive-compulsive disorder. It was philosophy. OCD, I thought, offered a wedge into the mind-brain enigma. Because symptoms are usually so clear-cut that patients can describe precisely what they feel, I realized that there should be no problem establishing the mental, experiential aspect of the disease. And since it was becoming clear even in the 1980s that psychiatric illness was rooted in the functional neuroanatomy of the brain, I was also optimistic that it would be possible to establish what was happening in the brain of people with the disease. Finally, the disease’s ego-dystonic nature suggested that although the brain was acting up, an intact mind was struggling to overcome it: the events
of the brain and the state of the mind were, at least partly, separable. Obsessive-compulsive disorder thus seemed to be the perfect vehicle for pursuing such profound questions as the schism between mind and brain and, in particular, the distinction between active and passive mental activity: the symptoms of OCD are no more than the products of passive brain mechanisms, but patients’ attempts to resist the compulsions represent active, mental effort.

What attracted me most to the psychological treatment of OCD, however, was a tantalizing possibility. Cognitive therapy—a form of structured introspection—was already widely used for treating depression. The idea is to help patients more clearly assess the contents of their thought stream, teaching them to note and correct the conceptual errors termed “cognitive distortions” that characterize psychopathological thinking. Someone in the grips of such thinking would, for instance, regard a half-full glass not merely as half-empty but also as fatally flawed, forever useless, constitutionally incapable of ever being full, and fit only to be discarded. By the mid-1980s, cognitive therapy was being used more and more in combination with behavioral therapy for OCD, and it seemed naturally compatible with a mindfulness-based perspective. If I could show that a cognitive-behavioral approach, infused with mindful awareness, could be marshaled against the disease, and if successful therapy were accompanied by changes in brain activity, then it would represent a significant step toward demonstrating the causal efficacy of mental activity on neural circuits.