Diagnosis of the day: Obsessive Compulsive Disorder

CHECK CHECK CHECK: Obsessive Compulsive Disorder is the label given to a anxiety disorders that have two chief characteristics: Obsessions (unwanted thoughts, images, beliefs) and/or compulsions (ritualized or repetitive behaviors). There are several subtypes. In contamination OCD, the sufferer worries about being affected by touching or being exposed to specific (although often many) people or objects, or being infected by germs. The fear is controlled where possible by avoidance (never touching doorknobs, refusing to shake hands, etc). When avoidance is impossible, the sufferer often develops rituals to "cancel out" the contamination. These may be logical though excessive, such as hand washing or use of antibacterial lotions. A person with contamination OCD may wash, scrub or apply chemicals to hands to the point of damaging the skin. Illogical rituals may also be used: retracing steps, saying a particular phrase, and so on. The rituals can be very time consuming and do NOT feel like a choice.

Rituals aren't limited to contamination OCD. Some OCD folks have intense fears something terrible will happen to them or someone they care about if rituals are not followed. Checking disorder, in which a person has intrusive concerns about not completing a protocol, may lead to checking and rechecking to make sure the lights are off, gas isn't leaking from the stove, or similar. Last year driving to the airport I saw a bumper sticker on a car that said "Are you SURE you unplugged the iron?" Like most people, I have a touch enough OCD  that it nagged me for a minute or two. For someone who really is affected by OCD, that might have led to a drive back home from over an hour away.

OCD can cause intrusive, usually illogical thoughts that cause distress. They are "ego-dystonic", a fancy way of saying the person doesn't want them. Those affected seek constant reassurance to refute them. In one case many years ago, I worked with a young man who worried he might be gay. He had never been sexually involved with a man, and never wanted to be. He had perfectly satisfying heterosexual relationships. Yet every week he would ask me "Are you SURE I'm not gay?" Reassuring someone with OCD is not effective, and in some ways contributes to the worry. The person with OCD knows their behavior or thinking is illogical. But it is not a choice to them.

"Pure O" OCD is the name given when the primary symptom is intrusive thoughts and/or images.  Disturbing sexual or violent pictures and thoughts are common in this type of OCD, but the name is misleading-- there are almost always some compulsions around being used to try to control the behavior.  For example, a person may avoid driving because of obsessive thoughts about running someone over.

I read once that the chief difference between the OCD and non-OCD person with egodystonic thoughts is the "stickiness" of their brain. We all think crazy thoughts. But if we don't have OCD, we dismiss them as random. The OCD brain worries them like the place where a lost tooth came out. They just can't leave them be.

The causes of OCD are unclear. There is an obvious genetic component that accounts for at least half of occurrences. While no one gene appears responsible, it's rare to treat someone with true OCD who didn't have one or more direct family members with some sort of significant anxiety disorder. But environment also plays a role. Life stresses, maternal pregnancy factors and even childhood strep infections can be factors. Hormones appear a factor at least in women-- it is common for new mothers (some say around 30%) to struggle with some intrusive thoughts and compulsive behaviors. Of course, stress and anxiety in such situations would be a clear contributing factor: is the baby breathing? Did I feed her enough? But the frequency leads researchers to conclude that hormones may exacerbate the situation. You can see in that case the evolutionary effectiveness of increased vigilance. Worried-over babies are more likely to survive than neglected or ignored babies.

OCD is different from Obsessive Compulsive Personality Disorder. People diagnosed with OCPD don't usually have rituals. Personality disorders are considered more personality types that cause trouble for people rather than isolated disorders. If you're old enough to remember "The Anal Retentive Chef" from Saturday Night Live, you've seen a classic OCPD type-- obsessed with rules and order, inflexible, fussy, perfectionistic. As I mentioned in my first blog about diagnosis, at their most basic most diagnoses describe a particular type of genetic predilection that have both strengths and weaknesses. You probably WANT your chef, your surgeon, the guy that lays your tile to be a bit on the obsessive-compulsive side. That means you will get a job done right. But when either of these slips into the really disordered arena, you get someone impacted so much by rigidity, anxiety, avoidance or time-eating practices they cannot function at all close to their potential. That's when it's time to do something.

Therapy for OCD
The most demonstrably effective treatment for OCD is not pleasant for those who have it. It involves systematic exposure to the triggering events so that the brain can rewire these to be perceived as non-threatening. OCD "boot camps" provide this quickly, though overwhelmingly. A person with contamination OCD might be forced to touch a toilet, for example, then eat something without washing. Generally, in outpatient treatment, exposure is done gradually to desensitize the person.

Medication can also be helpful. SSRIs (antidepressants such as fluxoetine, better known by its brand name of Prozac, or others) seem to help some people. There are risks and benefits to using medication and it appears that they work best when exposure therapy occurs concurrently. Medications of these sort should NEVER be stopped abruptly because serious withdrawal syndromes and rebound effects (worsening of symptoms) may occur.

New treatments using deep-brain stimulation (which involves surgery), transcranial magnetic stimulation (non-invasive) and even good old ECTs are also actively being explored to treat more severe and disabling forms of OCD.

If you're worried now that you have OCD, remember that most people have a little bit of every "disorder". The key factors for figuring out whether it's a problem is how disruptive it is to your life. Who's complaining? How much is it limiting you? If it's a problem for you, there are many options. Most cities (certainly Corvallis) have therapists and psychiatrists who specialize in treatment of OCD. Here are some other resources:

ocdtribe is an online source with chat groups and information by and for OCD sufferers.

The International OCD Foundation, also run by persons with OCD, distributes information, research, and connects folks to treatment.

Dr. Stephen Phillipson has several good articles here at OCD Online.

Lots of successful, famous people have OCD. Click this post's title to see Howie Mandel talk to David Letterman about his.

We'll end on a lighter note: an OCD song.

What's in a name? Diagnostic dilemmas

One the pleasures and pains of my job as a clinical social worker is to give a label to the variety of human experience that lead people to my office. If my clients choose to use--and are lucky enough to have-- therapy coverage, their insurance requires I give a diagnosis. It's a devil's deal: if you want to stay or get well, you better start off labeled sick. I've trained in diagnosis, both in school and through my many mentors and jobs. And I see the benefit shown, at times, in the relief of clients at having a name for what is ailing them. But it's a messy business.

Some of these diagnoses are reflective of the maladies that are standard to anyone who's lived long enough-- say, the ubiquitous "Adjustment Disorder" to a divorce, layoff, or newly emptied nest. Though considered a mild diagnosis, the "disorder" part rankles me. The experiences of life changes can be very disruptive, but being disrupted by them is too usual to qualify as an illness. However, the stress they invoke can and does cause real illness, the sort that costs insurance companies real money. It makes sense to attend to them. Somewhere in school or at a work conference you may have taken one of those "life stressor inventories" that gives a point value to experiences good, bad, anticipated and unintended. As your points increase, so do your chances of having a major medical event within the following year. Helping people find real tools to mitigate the damage is my job. And insurance requires a name for that damage.

But naming those names can be problematic. There's the very real stigma that media and individuals attach to it. If your gall bladder isn't working properly, you may be really uncomfortable; it's unlikely you're ashamed. But if your emotions, behavior or thinking is off it's a different story. Now it's REALLY personal. Our brains are organs--pretty complicated ones at that. Brain's function is dependent and reflective of a variety of processes: environmental (the nurture part, that is), biological, such as hormonal systems, oxygen levels etc and genetics. We are no more in charge of the DNA that regulates our innate response to stress than we are of the DNA that determines our eye color.

I've long believed that most things we call "disorders" are really just variations of genetics that have evolutionary function. Sometimes the side effects of those functions cause trouble, especially now that we are living much longer than is needed merely to reproduce and raise our young to a viable age. Sickle Cell Anemia is an example of that. Persons with this genetic mutation (read: random change) were much more resistant to childhood malaria, thus living long enough to reproduce. Reproduction passed that change along. When the average life span was 30-40, that was a real benefit to the population affected. Not so much when malaria is no longer an environmental threat for some with the mutation, and when life expectancy is much longer.

Genes that create a hypersensitivity to environmental risk-- or its opposite, a risk-taking, fearless approach to change-- both have reproductive advantage. Safety-conscious persons who are hyper-aware of their environment and actively avoid threats would have reproduced successfully in certain environments where their braver brothers and sisters walked into harm. Those same people would have been out-reproduced when factors required persons to disregard potential harm and immediate danger or discomfort in order to relocate for food, shelter, and so forth. We seem to have a reasonable minority of each of these groups still reproducing-- the anxious and the manic. Persons with hypomania, at least in its more benevolent form, can work for hours without sleep, be extremely creative, and take risks the rest of us deem unacceptable. Persons with anxiety, who can predict dangers unapparent to the hypomanic, mandate things like 8 hour shifts and OSHA rules.

Asperger "disorder" is another cultural definition of a spectrum of genetic variation that has its ups and downs. The Asperger variation probably is responsible for much of humanity's technological and engineering advances. The Asperger brain is often extremely skilled at spatial understanding, categorizing, ordering and patterning. It's not so hot at understanding emotional nuance. Which brain would be more useful to you in designing a building code to protect harm from earthquakes?

We get the brain we get. It's going to have quirks. It's going to have strengths and weaknesses. It is surprisingly more malleable at any age than we have ever previously understood. Within limits, we can challenge our innate tendencies and create new pathways of understanding that occur not just on a psychological but on a physical level.

I'll write more on that, and on diagnosis, in my next blog. Meanwhile, here's some additional readings on the profession's most fallible touchstone, the Diagnostic and Statistical Manual of Mental Disorders (aka DSM):

"81 Words" This American Life devotes the entire broadcast of episode 204 to the events surrounding the dissolution of the category homosexuality as a Certifiable Mental Disorder. It deserves to be heard as a cautionary tale of how popular, or at least powerful, opinion can be reified.

Opening Pandora's Box: The 19 Worst Suggestions for the DSM V Author Allen Frances, MD, was the chair for the DSM IV, and it's not surprising he might react to the revisionists. His bias is evident in this read-- a bit bitchy, even . Nevertheless, his article makes some good points about troublesome indications of pathologizing normal human experience and suffering.

DSM V Org: find the whole lollapalooza here, with highlighted changes and their rationales.

"Be careful how you view the world: It is like that." - Erich Heller

That quote appears, tiny, on my office door, and summarizes one way in which I approach therapy.  It is, as I wrote here, all about the story we tell ourselves.  It's not that evil doesn't exist, or good-- but  rather which story we are attending to, and feeding.  Unfortunately, and probably evolutionarily, it's the bad ones that grab us.  Luckily we are more than our biology.  Consciousness offers us an opportunity to question our assumptions or the predominant paradigms that insist no one is to be trusted, and nothing good will come of all of it.  Remember, although suffering is real, so is joy.  Add to it.

(for the record, dead kelp muppet above is an unretouched beach find...)

Tending the Tangled Garden

I hauled the big Red Book to work today.  In case you aren't familiar, this weighty tome is a facsimile and translation of Carl Jung's personal journal, replete with luminous, hallucinatory paintings of dreams illustrating his Hero's Journey.  Access a great NYTimes article on its publication here:  The Holy Grail of the Unconscious, by Sara Corbett.

Jung broke ranks with his analytic companions, chiefly Freud, when he took a less medical/pathological turn into decidedly theosophical territory with his writings and analysis.  He saw the unconscious as a repository for a wealth of material to be mined for a more wholly realized life.  Access could be gained through art, writing, dreams, myths-- all were sources of soul.

This morning before starting my day's work I opened to this passage:  "Wondrous things came nearer.  I called my soul and asked her to dive down into the floods, whose distant roaring I could hear...and thus she plunged into the darkness like a shot, and from the depths she called out:  'Will you accept what I bring?' "  In the dream, soul returns first with the detritus of war, next the remnants of historical magics and superstitions, then the horrors of which humanity has shown itself capable, and "fear, whole mountains of fear".  Each in turn Jung accepts, saying "I accept all, how should I dismiss anything?" But when soul comes back from the depths with the wisdom and treasure of all past cultures, he is overwhelmed.  "That is an entire world, whose extent I cannot grasp; how can I accept it?  Soul chastizes him sharply.  "But you wanted to accept everything?  You do not know your limits.  Can you not limit yourself?"  From this, Jung seems to face his grasping and lack of discernment.  He writes:  "I see that it is not worth conquering a larger piece of the immeasurable...A well tended small garden is better than an untended large one."  (Page305-306, Red Book, Carl Jung, edited by Sono Shamdasani, translated by S. Shamdasani, M. Kyburz and J. Peck, published by Norton 10/2009)

Plunging into the collective unconscious, or even dipping our toes in our personal subconscious, can be a frightening task.  In America, we do a good job of avoiding it.  We keep ourselves crazy busy, fortressed in stuff, cut off from nature, each other, and our own soul.  We feel a vague or real sense of dis-ease, or sometimes terror, and we run in absolutely the wrong direction in hopes of comfort.

Pink Floyd sang it:

When I was a child
I caught a fleeting glimpse
Out of the corner of my eye.
I turned to look but it was gone
I cannot put my finger on it now
The child is grown,
The dream is gone.
but I have become comfortably numb."
                   "Comfortably Numb" , Pink Floyd, The Wall, 1979

It's true, as the country folks say, that if you beat enough bushes you are going to drive out some snakes.
But with compassion and what Jung spoke of as modesty and cultivation, there is much to be had by digging a bit deeper.  Our lives go by more quickly than we imagine.  We find the things we worried about so much in a moment are nothing in the bigger picture.   And what we put off-- as I said once to a client, well you can deal with it now and there will be hell to pay.  But if you put it off-- it's hell to pay, plus interest.

What little piece of your garden has been neglected too long?  What waits for you there?

Today's quote:  It is by going down into the abyss that we recover the treasures of life. Where you stumble, there lies your treasure.  Joseph Campbell

Today's song: