MINI MEDICAL SCHOOL #4
OBSESSIVE-COMPULSIVE DISORDER AND ST
Two months ago, Howard asked me to write an article for this magazine about obsessive-compulsive disorder, and-as I have done with every article I have written over the years for this journal--I have obsessed over it for weeks, the ideas constantly gnawing my brain, forcing out other productive activity and robbing me of peacefulness. Writing is extremely painful for me, probably because I feel incompetent at it and because I have the (unrealistic) belief that my articles should be "perfect." In short, ladies and gentlemen, I am afflicted with a small measure of the very problem about which I am charged to write.
In the weird and wonderful realm of psychiatric disease and disorders, there are found among the classifications of maladies many different types of demons. Many are nearly always true disasters for the havoc they cause, like schizophrenia. Others, like anxiety disorders, can be managed reasonably well with proper diagnosis and treatment. Still, others are so pervasive that they overtake an entire personality, often ruining the lives of the afflicted one as well as those around him/her. Unlike the so-called affective (AFF-ek-tiv) disorders such as depression and bipolar disorders, or the thought disorders such as schizophrenia--which affect certain (more or less) isolated aspects of consciousness such as mood (affective disorders) or the ability to tell reality from fiction (schizophrenia)--the personality disorders invade a person's entire mental being. As such they, by definition, interfere with their ability to function in many ways, including work, family life, friendships, and intimate relationships such as marriage. There are several different types that are defined, many of which you may already be aware of, such as Antisocial PD (repetitive liars and con artists), Narcissistic PD (many politicians and doctors), and Histrionic PD (actresses and "overly-dramatic" types). These people may appear to have the "good life" to the public, but their family and associates know how impossible these people can be to live and work with.
Then there are the afflictions that are on the borderland of psychiatry and neurology. By that I mean that physicians have traditionally considered these to have origins in both the mental and the physical origins of the mind. Nowadays, we really believe that nearly all psychiatric disease is based on either inherent brain abnormalities (those you have just because) or those that have resulted from aberrations of development (either from bad experiences or genes or injury or luck). Thus, whereas schizophrenia used to be attributed to "bad parenting," we now know it to be a common (1%) medical condition that has almost nothing to do with what happens to you when you're young. The same is true of depression, although we all know that in this case our circumstances highly affect the manifestations of this serious illness. Similarly, there are certain disorders that have previously been misunderstood as purely psychiatric conditions caused by stress or some other nonsense that have ultimately been shown to be mostly medically based. The one most dear to you the reader is dystonia, now universally accepted as a classic neurological disease. Another is my favorite thorn, Tourette's Syndrome, which causes me to grimace and wink uncontrollably and which now is clearly understood to be a heritable medical condition.
But the topic of this article is another little oddity, one that in various severities is ubiquitous. Obsessive-Compulsive Disorder (OCD) is classified with other conditions that collectively are called "Anxiety Disorders," and include panic disorder and the various phobias. OCD itself is marked by anxiety (i.e., fear that is directed at no particular threat) and is characterized by the presence of recurrent and persistent thoughts, impulses, or images that are intrusive, even when the person tries to ignore them (obsessions); and associated with compulsions, which are repetitive behaviors (e.g., hand washing, ordering objects, checking to be sure something is a particular way) or mental acts(e.g., praying, counting, repeating words silently that a person feels driven to perform in response to an obsession or according to rules that must be applied rigidly). Performing these acts temporarily relieves the inner anxiety. In its minor forms OCD is very common. For example many of us have found ourselves counting how many steps we take between cracks in a sidewalk or how many tiles there are in the ceiling above us. Such benign behaviors are normal; but when we are distracted by them to the point that other aspects in our life are adversely affected, then OCD becomes a real condition.
Last year TV introduced the nation to a quirky new detective called "Monk," a fictional character who, like Columbo a generation before, broke the stereotype of the hard-driving cop. As fastidious as Columbo was rumpled, Monk has a relatively severe case of OCD. At times he has to avoid touching certain objects or has to arrange criminals in just a certain way before he can bring himself to arrest them. If these rituals or compulsions are not fulfilled, he is paralyzed by fear and anxiety. Yet he is so clever that he sometimes uses these traits to his advantage. You can see him on the USA network at 10:00 P.M. on Fridays.
It has long been observed that tics (repetitive, involuntary, brief motor movements or vocalizations) are often seen in people with OCD traits, too. In fact, as I can attest, the performance of a tic is very similar to the ritualistic behaviors seen with compulsions-only briefer and less fully developed. Both are temporarily suppressible, the way you can for a time avoid scratching an itch. But like an itch, the sensation that arises from avoiding the action is overwhelmingly dysphoric (uncomfortable physically and mentally).
Since dystonia has some features that are similar to tic disorders, such as repetitive muscle activity that fluctuates in intensity, some have wondered whether OCD is more common in people with dystonia, too. In 1992 Drs. Bihari, Hill, and Murphy at the NIH studied whether patients with spasmodic torticollis had a higher prevalence of OCD than "normal" controls. They found that the 22 patients with spasmodic torticollis had significantly higher scores than 29 controls on two commonly used tests that measure the presence of OCD. This study supports the theory of a link between psychiatric disorders and certain movement disorders, particularly dystonia. Some of you may recognize the features of OCD in yourselves (for a more detailed discussion go to HYPERLINK "http://www.psychologynet.org/ocd.html" www.psychologynet.org/ocd.html ). This is not surprising, and perhaps by recognizing the symptoms you might be able to help yourself feel better. In fact although OCD, like dystonia, is not curable it is treatable to a large extent. Many of the so-called SSRIs (selective serotonin reuptake inhibitors) have been use successfully to help many people with OCD. Paxil has actually been approved by the FDA for use in OCD, and most of the other ones, too, (like Zoloft, Prozac, Celexa, Lexapro, Effexor, and others) are probably also very good. Of course, medications are not the answer to everything, and not everyone needs treatment for OCD, but if you find that you are troubled by this condition, you should speak to your doctor about how you may get help. Perhaps you should make it an obsession.
Matthews Gwynn, MD (The Botox Doc)
993-F Johnson Ferry RD NE Suite 120
Atlanta, GA 30305
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