OCD is a common condition typically affecting between 1 and 2.3 percent of adults in the US.
Being scrupulous is a positive human trait and the word is aimed to describe humility, self-doubt and verifying one’s ideas and work. However, it became evident in the Middle Ages that the scrupulosity (an exaggerated form of scrupulousness) can be a dangerous mental phenomenon. For example, Martin Luther was tormented by recurrent thoughts of his infidelity to God and other demeaning thoughts that entered his head.
English philosopher Samuel Johnson performed strange rituals as part of his daily life. More recently, the famous aviator Howard Hughes was so preoccupied by germ contamination that he had his bedroom curtains rot rather than touch them or move them and slept naked in a white sheet to avoid germs.
Manifestation & presentation of OCD:
Although OCD is currently differentiated into obsessions and compulsions, this is an artificial divide. Patients with OCD manifesting as self-doubt will not only have recurrent; thoughts, they also conduct many rituals to overcome them.
Fear of germs, fear of being unclean in body and thought, self-doubt about self-worth, and resultant repetitive, uncontrolled checking are all common presenting and troubling symptoms.
It is unclear if the obsessions and related rituals cause anxiety or angst or relieve it. Although it is well known among patients with OCD, times of stress such as new job, examinations, pregnancy and childbirth lead to an increase in the symptoms, most patients subjectively feel relieved for short times if they let the obsessions and rituals go unchecked. So, in some ways, this becomes a chicken and egg question, without providing additional insight into the illness.
These obsessions and rituals can take on such a severe form that sufferers can lose touch with reality and behave in bizarre ways.
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Causes and treatment:
There is no known cause for the occurrence of OCD, although it tends to run in families. Historically, treatment by religious penance and cleansing of the mind were considered as treatment options, although, evidence for their effectiveness is absent. In general OCD is thought to be one of the mental illnesses that is resistant to psychotherapy. Cognitive Behavioral Therapy may have modest effects.
None of the new psychiatric medications discovered in the 1950s and 1960s seem to have observable effect on patient’s OCD symptoms and signs. In this context, one of the intriguing phenomena that was observed by Dr. Jambur Ananth* in Toronto was a major breakthrough, suggesting the potential role of serotonin, a brain neurotransmitter.
While as a young researcher, Dr. Ananth was looking at the data comparing two antidepressants called imipramine and clomipramine in a clinical trial. He noticed that depressed patients assigned to clomipramine as their treatment had a noticeable decrease in OCD symptoms (self-doubt, fears and rituals of a milder degree are common in depressed patients).
Based on this finding Dr. Ananth suggested that OCD may be caused, in part, by a low activity of serotonin in the brain. This was based on the available data suggesting that clomipramine has a larger effect of increasing brain serotonin compared to clomipramine.
Following this, several pharmaceutical companies developed clomipramine (Anafranil) and other serotonin enhancing agents such as fluoxetine (Prozac), sertraline (Zoloft) and Paroxetine (Paxil) for marketing purposes. The interesting phenomena is that OCD symptoms and signs are relatively insensitive to non-specific treatments that are termed as placebo response**. Because of this, clinical testing for these medications has been easy and many of these medications easily passed the tough testing set up by the US FDA.
However, these medications that enhance the serotonin systems have only a modest effect for most OCD sufferers. As a rule, a reduction of 25% to 35% of the symptom intensity is decreased. In other words, these medications take off the edge, but the sufferers still have many leftover symptoms and signs. Luckily, suicide risk is relatively low among OCD sufferers***.
Alternative treatments:
Among severe cases of OCD, specialized neurosurgical procedures such as cingulotomy among many has been tried for over 80 years with mixed results. Other techniques such as Deep Brain Stimulations are research tools undergoing testing at the National Institute of Mental Health in Bethesda, Maryland.
Medications that do not work through the serotonin enhancement are being tested at the Northwest Clinical Research Center. The details of this study can be found at the ClinicalTrials.gov.
Current OCD Study at NWCRC
Find out about our current OCD Study and see if you would like to participate!
References:
* Ananth, J., Solyom, L., Bryntwick, S., & Krishnappa, U. Clomipramine therapy for obsessive compulsive neurosis. American Journal of Psychiatry, 1979, 135, 700–701.
** Khan A, Kolts RL, Rapaport MH, Krishan KR, Brodhead AE, Brown WA. Magnitude of placebo response and drug placebo differences across psychiatric disorders. Psychological Medicine. 2005;35:743-749.
*** Khan A, Leventhal RM, Khan S, Brown WA. Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database. Journal of Affective Disorders. 2002;68:183-190.
