Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of Obsessive-Compulsive Disorder

Prologue: A Personal Perspective

I suffered obsessive -compulsive disorder myself while in medical training. Terrifying, tormenting thoughts often popped unbidden into my mind, causing surges of panic and piercing discomforts. The thoughts usually took the form of vibrant, violent images, for instance, of a knife being thrust into my flesh, or of my nose being scraped right off in a car accident. A particularly frequent one was that of my hand being punctured by a phlebotomy needle. I would have the sudden, intrusive image of me standing at a patient's bedside ready to draw a sample of blood: I unsheath a large-bore phlebotomy needle, menacing, daggerlike in its appearance, and then inexplicably, instead of inserting the needle into my patient's vein, I thrust it to the hilt into the thenar eminence of my hand. Upon the occurrence of this frightful fantasy, my hand would ache in a manner that seemed indistinguishable from genuine pain. I would shake it to make it feel better.

It was fortunate that these troublesome intruders into my consciousness rarely struck when I was engaged in important activities and that therefore they did not upset my medical career because they were impossible to fend off. The more I resisted them, the worse they became. I often used counter-ideas, or restorative images, to neutralize them. To counteract the phlebotomy-needle thought, I would imagine an impenetrable cream covering my hand. The needle would strike and promptly burst into pieces. The image would fade. Yet the tormenting fantasy would always return at another time.

What I suffered, I learned later, was a typical form of obsessive-compulsive disorder. Mytormenting thoughts were obsessions, and my counteractive ideas were compulsions. I know now that by fearing them and fighting them, I only made them worse. But back then I didn't know any better.

What did I do for help? Since I later went on to study psychiatry, you'd think that I might have gotten therapy: probed into my unconscious, teased apart my ego defenses, scrutinized my childhood--at the very least, come to some sort of an understanding of my problem. Nothing of the sort. When my obsessions were not bothering me, I didn't want to think about them. I kept my tormenting thoughts a secret, as most OCDers do. Given the treatments that were available back then, it was probably just as well.

In the early I970S, mental health professionals knew next to nothing about obsessive-compulsive disorder. The field had come no further than had the great psychoanalyst Sigmund Freud, who candidly admitted that OCD baffled him. His own theories on the subject, Freud once said, were no more than "doubtful assumptions and unconfirmed suppositions."

When I was in training, the psychiatrists, psychologists, social workers, nurses, and counselors who treated OCD sufferers had trouble just identifying obsessions when they saw them. The self-tormenting thoughts were considered rare, and as a result they were rarely recognized. Severe cases were routinely misdiagnosed as hallucinations; mild ones were written off as examples of obscure unconscious conflicts.

On those occasions when OCD was correctly diagnosed, treatment was next to worthless. They tried years of psychoanalysis, counseling, and group therapy; they prescribed antidepressant medications, antipsychotic medications, even shock therapy; but therapists themselves believed that OCD was a dark and mysterious illness, essentially incurable. That's what I was taught in medical school. If a patient had severe OCD, my professors would just shake their heads, intimating, "We'll do our best, but don't expect much." One clinician of that era wrote, "Most of us are agreed that the treatment of obsessional states is one of the most difficult tasks confronting the psychiatrist, and many of us consider it hopeless."

The good news is that times have changed.

The study of OCD has undergone a truly remarkable shift in emphasis, as researchers have turned away from unproven theories and jumped with both feet into the research lab. As a result of this dramatic change, our understanding of OCD has leaped forward. At a recent meeting of the American Psychiatric Association, more special reports were presented on OCD than on any other topic. OCD has been referred to as the "hot topic" of the I99OS, and professional journals are overflowing with updates on the chemistry, genetics, psychology, and treatment of obsessions and compulsions. The great news for OCD sufferers is that obsessive-compulsive disorder is now recognized as a common, physical disease for which effective treatment is available.

OCD: The Hidden Epidemic

When I was in training, psychiatrists estimated the incidence of a given mental disorder in the general population by extrapolating from the number of people known to be in treatment. Since back then only a tiny number of patients were diagnosed as having obsessive-compulsive disorder, OCD was thought to be very rare. The figure most commonly quoted for its overall incidence was a minuscule .05 percent.

What was not appreciated back then, however, was how adept OCDs are at keeping their disorder hidden. The effort they expend in scheming and lying often rivals that spent on the disorder. Afraid people will think they are crazy, OCD sufferers don't tell anyone about their illness--not their families or their friends, and certainly not their therapists. As Freud, who did not get much else right about OCD, astutely noted: "Sufferers [from OCD} are able to keep their affliction a private matter. Concealment is made easier from the fact that they are quite well able to fulfill their social duties during a part of the day, once they have devoted a number of hours to their secret doings, hidden from view."

The true incidence of obsessive-compulsive disorder was not uncovered until 1983, when the National Institutes of Health announced the findings of the first large-scale study on the rate of occurrence of mental health disorders in the general population of the United States. Researchers went from door to door in five different areas of the country, carefully interviewing 18,500 randomly selected people. The results took mental health professionals completely by surprise: OCD was found to occur in 1.9-3.3 percent of the population! Although some researchers have questioned the reliability of the NIMH study on the grounds that its diagnostic criteria were not sufficiently stringent, there is general agreement that OCD's incidence is at least in the range of 1-2 percent.

The experts had misjudged OCD's incidence by a factor of more than twenty. Instead of 150,000 people having the disorder, millions have it. OCD turns out to be one of the most common of all mental illnesses, with large numbers of people suffering the disease in silence. Harvard's Michael Jenike, a leader in OCD research, has referred to it as mental health's "hidden epidemic."

OCD As a Biological Disorder

When I was in medical school, the leading theory on the cause of obsessive-compulsive disorder was Freud's: Obsessions and compulsions arise from unconscious conflicts between instincts, particularly the sex drive, and attempts at self-control. Once widely accepted, this theory no longer holds sway. Extensive research in biochemistry, pharmacology, radiology, and genetics has now demonstrated beyond a doubt that OCD results directly from an abnormality in the brain's chemistry, a malfunction that leads to faulty firing of the brain's neurons. As succinctly put by Yale Medical School Professor Richard Peschel, "Recent neuroscience research proves that obsessive-compulsive disorder is a physical, neurobiological disease of the brain."

That a physical, not a psychological, abnormality accounts for OCD seems, at first, surprising, but the same discovery has been made in a number of other mental disorders. Neurosyphilis, a severe form of the venereal disease that causes heightened emotions and changes in behavior, and pellagra, a vitamin deficiency that leads to fatigue and anxiety, were once thought to be due to psychological conflicts. Early in the twentieth century, however, it became clear that both were entirely curable, biological diseases. More recently, bipolar disorder and schizophrenia, two of the most severe psychiatric problems, have been demonstrated to be physical illnesses. As England's Richard Hunter, past president of the Royal Society of Medicine, has pointed out, "Progress in psychiatry is inevitably and inexorably from the psychological to the physical--never the other way around."

In the case of OCD it is crucial that this shift in perspective, from psychological to neurobiological, be fully accepted as quickly as possible. For one thing, many people are convinced that if a disorder is called "psychiatric," it is not real. Insurance companies, ever eager to find ways of denying payment, routinely assert this fallacy. What a terrible burden it is for disabled OCD sufferers to be viewed as people who are too weak to deal with life's stresses, or worse, as impostors trying to get out work.

Furthermore, OCD patients themselves readily embrace the new neurobiological view. In the past when I explained to my patients that they had a disorder caused by childhood conflicts, they often promptly disappeared from treatment. In the rural area where I practice, at least, people do not want to hear that they have deep-seated problems resulting from the way they were brought up. Now when I explain to patients that they have a medical disorder--an illness like diabetes or heart disease--they nod in agreement. For those who suffer the disorder, the physical explanation of OCD has the ring of truth.

Most importantly, the unlocking of the neurobiological underpinnings of OCD has led to new and potent treatments for the disorder.

Effective Treatment For OCD

Back in the early 1970s, there were no effective treatments for OCD. Now there are not just one but two that work: behavior therapy and a new group of "serotonergic" medications. These two new therapies represent truly spectacular advances in the treatment of mental disorder. Certainly, if these therapies had been available twenty years ago, and I had known then what I know now, I would have unhesitatingly used them to treat my own OCD. As I will mention later, I do currently use an anti-OCD medication.

Behavior therapy came on the scene first, in the late 1970s. Bearing no resemblance to psychoanalysis's hunt for hidden conflicts, behavior therapy's goal is simply to transform troublesome behaviors. In behavior therapy for OCD, obsessions and compulsions are first clearly identified, then rated in order of severity, and finally targeted for special homework assignments. Behavior therapy has turned out to be a remarkably successful treatment for OCD. A dozen good studies in the last fifteen years have reported significant improvement in 60-70 percent of patients. A 1994 study using an intensive program developed by Edna Foa of Medical College of Pennsylvania showed a marked reduction in obsessions and compulsions in more than 75 percent of the patients.

Only a few years after the introduction of behavior therapy, a group of medications affecting the brain chemical serotonin appeared as a second effective treatment for OCD. It is truly amazing that two totally different, potent therapies for OCD emerged in such a short span of time. Five members of the serotonergic group of medications are now available in the United States: fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), and clomipramine (Anafranil). All work to lessen obsessions and compulsions. Clomipramine has been the most studied of the group. A 1989 study of a large number of OCD patients from twenty-one different university centers in the United States showed that 60 percent of the patients treated with clomipramine were much improved, while the number much improved with placebo was less than 10 percent.

Like most OCD specialists, I routinely treat OCD with a combination of behavior therapy and serotonergic medications. Happily, the two cause no problems when used together. On the contrary, each seems to enhance the effect of the other. According to John Greist, M.D., OCD specialist from University of Wisconsin, "Medications and behavior therapy now are able to help go percent of people with OCD." This in a disorder recently thought to be hopeless.



My field of psychiatry--the branch of medicine that once brought you lobotomies and penis envy--has been getting things right lately. Tremendous progress has been made in the understanding and treatment of a number of syndromes, including schizophrenia, bipolar disorder, major depression, panic disorder, and attention deficit disorder. The advances in obsessive-compulsive disorder are the most impressive of all.

A good case can be made, in fact, that no other disorder in the history of medicine has ever experienced such an explosive growth in scientific understanding that has led to such a revolution in how it has been viewed: from regarded as rare to recognized as common; from presumed psychological to proven neurobiological; from written off as hopeless to accepted as one of the most responsive of all mental disorders to therapeutic interventions. All this has happened to OCD in about twenty years.