OCD: An Overview

Obsessive Compulsive Disorder (OCD) is often a source of humor and excuses by those who don’t have it, but it is a debilitating illness. This paper will define OCD, examine its symptoms, and probe treatments.

DEFINITION AND CAUSES: OCD is defined by its chronic symptoms, obsession and compulsion. Obsessions are thoughts, images, and urges that precipitate extreme anxiety (American Psychiatric Association [APA], 2013; National Institute of Mental Health [NIMH], 2016; Rachman and de Silva, 2009) Everyone has intrusive thoughts. Adam (2014) cites an experiment by Rachman and de Silva (1978) where people with OCD and unafflicted subjects were asked to list their weird thoughts over a two week period. When these were presented to a panel of experts, the experts could not distinguish the cards written by OCD sufferers from those written by the control group. What distinguishes the thoughts of OCD sufferers, this study suggests, is intensity, an inability to shut the thoughts down.

Compulsions are repetitive or ritualistic actions which an OCD sufferer performs repeatedly in response to some obsession or personal and rigid code of rules. (APA, 2013). Everyone checks or does things repetitively at some time during their day, but the person with OCD performs them so repetitively that she will spend an hour or more doing them each day or the thoughts and actions will disrupt their social, occupation, and other lives. (APA, 2013) The aim may be to relieve anxiety or to prevent some horrible catastrophe from happening. (APA, 2013, Rachman and de Silva, 2009)

Many theories attempt to identify the causes of OCD. This paper will briefly look at three: behaviorism, cognitive approaches, and biological theories.

Behaviorists hold that OCD is a learned behavior, an anxiety acquired through some trauma. They support this by the fact that OCD relieves anxiety. But they fail to explain why many patients cannot recall a triggering event. Nor can it explain the obsessions which appear to drive the ritualistic compulsions (Rachman and de Silva, 2009).

Cognitive modelers look to thought patterns. The Obsessive-Compulsive Working Group identifies six errors in thinking common to OCD patients who believe (1) the mind has the power or the responsibility to stop disasters and other negative outcomes; (2) bad thoughts can cause negative events or that thoughts are the moral equivalent of actually doing bad things; (3) it is possible to have total control over one’s thoughts; (4) Negativism; (5) Perfectionism; and (6) there is no uncertainty (Beyond OCD, 2017).

While the cognitive approach offers a thorough description of thought patterns, it does not explain what causes it. Biological researchers offer the explanation that an inadequate supply of serotonin causes symptoms. Critics argue that cognitive therapies are as effective as psychopharmaceutical treatment (Rachman and de Silva 2009). New research holds that an overactive signal pathway in the amygdala may be the culprit, offering new treatments (Ullrich, Weber, Post Poop, Grein, Gonzalez, Kreis, Üçeyler, Lesch, Schmidtt, Schuh, 2017).

WHAT OCD LOOKS LIKE: Adam (2014) cites the first case of OCD in the medical literature, “Madamoiselle F.” (Esquirol, 1845/1938). A French woman and accountant was obsessed with the thought that she was a thief. So she refused to wear aprons, removed the hems of her dresses, avoided handling money, rubbed her feet to remove any money that might have insinuated itself between her toes, shook her hand vigorously to do the same with her fingers, and checked and rechecked her books despite her reputation for honesty. Esquirol labeled her affliction as monomania, a partial insanity because she was aware of her madness as are most OCD sufferers.

The writer knows a few people with the disorder and many more who self diagnose. Self diagnosis and exaggeration of symptom was the subject of research for therapists and psychiatrists working at a clinic dedicated to OCD. Examining ten suspect cases, they found these clients tended to describe their symptoms using highly technical language harvested from the DSM which did not match the descriptions used by bona fide cases. Furthermore, the patients often manifested the nocebo effect where they developed unusual and undocumented side effects from the medications they were prescribed. Other mental disorders were frequently identified for this group. When they were questioned about their self diagnosis, many became angry and defensive. One man “pulled a knife from his waist, placed it on the table, and asked why the doctor did not believe that he had OCD” (Fontenelle, Lins-Martin, Natalia, Meica, Lima, de Menezes 2014). Clearly the popularization of the illness in best-selling books and television shows such as Monk has had its effect in creating a personality or other illness based obsession with having OCD.

The writer’s friends have genuine OCD diagnoses. One kept poking at the bridge of his nose until one day his finger slipped and he jabbed himself in the eye, detaching his retina. Another cannot go to bed without checking every door, window, lock, and appliance. This chore can take her more than an hour. She worries that her adoptive daughter mimics the behavior. Dematillomania, a disorder on the OCD spectrum, afflicts another friend of his. She picks at her face at the slightest sign of acne until she cannot go out. Others are concerned with germs and their appearance. (Sax 2017)

Obsession with contracting HIV bothers many OCD sufferers. Rapoport began noticing this trend in germophobia arising before the publication of her best-selling book in (1989). One of her patients lost his job after having a brawl over whether a co-worker should get an AIDS test. Adam (2014) says that he acts as if it is still 1988 at the height of the AIDS scare. He contrasts himself with Andy Warhol who would not eat food prepared by other gay men or wear clothes that had been washed and folded by gay men. Warhol, Adam argues, did not display OCD because he was acting on the best common knowledge of his time. Adam, on the other hand, obsessively calls HIV hotlines to check if he has been infected with HIV and should get an AIDS test – he is always told that he has nothing to worry about – but he is never convinced that he is not in danger. Louise was convinced that she was HIV positive, so she showered for hours, washed her hands and feet several times a day, and wouldn’t prepare or touch food for fear that she might contaminate it. Her ultimate catastrophe was infecting and killing her friends and family (Stuart 2017).

Shannon Shy’s illness took a different course. He rose to the rank of Lieutenant Colonel in the Marines despite his illness. Whenever he saw a car by the side of the road, he worried that there might be a dead body. Even though he tried to ignore the compulsion to stop, he often found himself turning around to check to be sure that everything was all right. He also obsessed over the covers of underground gas tank at filling stations: he would not step on them and otherwise avoided them. If he happened to drive over one, he would run to tell the attendant what he had done because he feared he might have caused an explosion or a fire. When he served as Officer of the Watch, he meticulously recorded every petty event that happened on his shift lest he leave out something that might be important. Other officers went out of their way to serve with him. He finally sought help when he heard the sound of a piece of lumber falling to the ground and imagined it was gunfire. There was no doubt that the lumber had caused the sound – he saw it fall. But he turned back and drove around until he found a pair of police officers who politely took his report (Shy 2009).

A Swedish study found that children with OCD experience more sleep disturbances than children with psychosis or school children of comparable age. This correlation awaits further research (Ivarsson and Larsson 2009). Another study, also out of Sweden, showed that people living with OCD have a higher suicide rate than those suffering from other psychiatric illnesses as well as the general population (Fernandez de la Cruz, Rydell, Runeson, D’Onofrio , Brander, Ruck, Lichtenstein, Larsson, Mataix-Cols 2016). OCD is not only a debilitating illness but a dangerous one.

TREATMENT: Psychiatrists prescribe SSRIs such Fluorhexidrine to control obsessions, compulsions, and accompanying anxiety. Anafranil – a tricyclic antidepressant has been used successfully since the late 1980s when Rapoport used it with her patients. The finding that overactivity of the receptor tyrosine kinase TrkB is at the root of OCD suggests that cancer drugs controlling the Ras/ERK-MAP kinase cascade may be of help (Ullrich, Weber, Post Poop, Grein, Gonzalez, Kreis, Üçeyler, Lesch, Schmidtt, Schuh, 2017).

Psychosurgeries – including brain surgery, Gamma knife, and Deep Brain Stimulation — have proved helpful in some severe cases.

SUMMARY: Obsessive-Compulsive Disorder is a debilitating illness with its origins in the amygdala. Sufferers can experience symptoms that cripple their ability to function. The intensity of the obsessions may lead some to attempt to escape their pain via the avenue of suicide. New research offers the hope of new treatments using already available cancer drugs. It is not something to be joked about.

Citations

Adam, David. (2014). The Man Who Couldn’t Stop: OCD and the True Story of a Life Lost in Thought. New York: Sarah Crichton Books, Farrar, Straus and Giroux.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Beyond OCD. (2017). What causes OCD? Retrieved April 30, 2017 from http://beyondocd.org/information-for-individuals/what-causes-ocd/.

Esquirol, J. (1845/1938). Mental Maladies: A Treatise on Insanity. Philadelphia: Lea and Blanchard. Cited in Adam (2014).

Fernandez de la Cruz L , Rydell M , Runeson B , D’Onofrio BM , Brander G , Ru?ck C , Lichtenstein P , Larsson H , Mataix-Cols D (2016). Suicide in obsessive-compulsive disorder: A population-based study of 36,788 Swedish patients. Molecular Psychiatry, 2016 Jul 19. doi:10.1038/mp.2016.115

Ivarsson, Tord and Larsson, Bo. 2009. Sleep problems as reported by parents in Swedish children and adolescents with obsessive-compulsive disorder (OCD), child psychiatric outpatients and school children. Nordic Journal of Psychiatry. 63:6. DOI: 10.3109/08039480903075200

National Institute of Mental Health (2016). Obsessive Compulsive Disorder. Retrieved April 30, 2017, from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml.

Rachman, Stanley and de Silva, Padmal. (1978). Abnormal and Normal Obsessions. Behaviour Research and Therapy, 16, pp. 233-48.

Rachman, Stanley and de Silva, Padmal (2009). Facts : Obsessive-Compulsive Disorder : The Facts (4th edition). Oxford, England: Oxford University Press.

Rapoport, Judith L M.D. 1989. The Boy Who Couldn’t Stop Washing: The Experience and Treatment of Obsessive-Compulsive Disorder. Boston: E.P. Dutton.

Shy, Shannon. 2009. “It’ll be Okay.”: How I Kept Obsessive-Compulsive Disorder (OCD) from Ruining My Life. Bloomington, Indiana: Authorhouse.

Stuart, Ralph. (2017). The OCD Stories: Stories that educate and inspire those with OCD. Kindle edition downloaded March 28, 2017 from https://www.amazon.com/OCD-Stories-educate-inspire-those-ebook/dp/B06XVF7DNM.

Ullrich M, Weber M, Post A M, Popp S, Grein J, Zechner M, Guerrero González H, Kreis A, Schmitt A G, Üçeyler N, Lesch K-P, Schuh K. 2017. OCD-like behavior is caused by dysfunction of thalamo-amygdala circuits and upregulated TrkB/ERK-MAPK signaling as a result of SPRED2 deficiency. Molecular Psychiatry. DOI: 10.1038/mp.2016.232 cited in University of Würzburg. 2017. Cause of obsessive-compulsive disorder discovered. ScienceDaily. Retrieved May 8, 2017 from www.sciencedaily.com/releases/2017/03

Creativity, Mood Disorders and Treatment

Modified from my post on PsychCentral
link

It has been noted that there seems to be a correlation between mood disorders and creativity. Many great artists, poets, writers, musicians have been troubled with mental health issues: Ernest Hemingway, Carrie Fisher, Kurt Cobain, to name a few.

Jim Phelps, M.D. writes on his website how some evolutionary biologists believe that there is an advantage to having a small dose of bipolar genes (similar to having a trait), advantages like: creativity, courage, productivity. 1 The idea of having a bipolar trait is one theory.

There are people who worry that treating their disorder will cause them to lose their creativity. But, if you are manic you can have disorganized thinking and jump from project to project, which would have a negative impact on your art. There are other consequences of mania which I will discuss further, along with the typical depressive episodes.

The questions revolving around medication, mood disorders and how it impacts one’s creativity have been pondered, and displayed in movies, like, “Touched With Fire”, which follows 2 hospital patients with bipolar disorder and how they come to grips with losing mania through treating their disorder.

Mania or hypomania may sound appealing. That is unless you have dealt with them and the aftermath.

Some symptoms of mania include:2

• Feeling unusually “high” and optimistic OR extremely irritable
• Unrealistic, grandiose beliefs about one’s abilities or powers
• Sleeping very little, but feeling extremely energetic
• Talking so rapidly that others can’t keep up
• Racing thoughts; jumping quickly from one idea to the next
• Highly distractible, unable to concentrate
• Impaired judgment and impulsiveness
• Acting recklessly without thinking about the consequences
• Delusions and Hallucinations (in severe cases)

With impaired judgement one can run up bills they cannot afford, gamble away savings, have affairs, and other problems, that must be dealt with when the mania subsides.

I don’t just have traits of a mood disorder. I would not be able to function without my medication. It is not even a question; the risks of medication are worth the benefits for me.

I do have periods when I have increased energy. The thoughts flow faster. The ideas come easier. I usually have a lot of fatigue, so it is a change for me when it occurs . But, I have hit a roadblock now. My mind has stalled. I can get things done, but new ideas don’t come easily. There is nothing I know of that I can do. I just must try harder and wait for my mind to clear.

There is plenty of hope for treating mood disorders and for being creative while treatment compliant.

One reader posted that the art goes on but it’s form may change.

1. http://psycheducation.org/the-biologic-basis-of-bipolar-disorder/chapter-5-the-big-picture/

2. https://www.helpguide.org/articles/bipolar-disorder/bipolar-disorder-signs-and-symptoms.htm

Trusting Your Moods with a Mood Disorder

First published Psych Central

https://blogs.psychcentral.com/triple-winner/2017/03/trusting-your-moods-with-schizoaffective-disorder/

I have a thought and mood disorder called schizoaffective disorder. It is similar to bipolar disorder, in that I have mood swings with periods of mania and depression.

When I was treated for my first severe manic episode I was heavily sedated and slowly titrated down on the medications. When I got to a dosage where I was no longer sedated, and my symptoms were under control, I started to feel okay, good even.

 

It scared me. “Would I feel too good?” I voiced my concerns to my psychiatrist and he reminded me I usually have other symptoms that precede mania. I think most people do.

You could go through a list of symptoms and see which ones are typical for you that would be noticeable.

Do you spend a lot of money?

Are you impulsive?

Do you talk fast?

Do you start lots of projects?

A lot of people monitor their sleep. I often have trouble with insomnia, so that isn’t a particularly good indicator for me. One thing is that I get irritable. I am usually pretty mellow, so if I start snapping at people that is a good sign that something is off. My psychiatrist also told me if people are looking at me strangely that is a warning sign. I am not sure if he meant I do strange things or I get paranoid, which I do, and get suspicious.

Isn’t everyone entitled to an off day, though? Sometimes when I am upset at someone, it is for a good reason. A lot of people imagine others think poorly of them, once in a while.

It would help to have someone I trust, tell me if I didn’t seem right. I have trouble with trust, though, when I am symptomatic. I think everyone else has the problem and I am fine. I am working on that, because I know it is important. Otherwise, you can have a great list of warning signs, but deny them. “I’m not talking fast, you are just listening slowly”.

Once you notice these warning signs, what do you do? That is a million dollar question.

This is where it is best to consult with your doctor and find out when they want you to contact them.

It is also good to come up with a  Wellness Recovery Action Plan (W.R.A.P.) to prepare.

It is good to catch things early, but you don’t want to be worrying every time you have a bad, or good, day.

To the Couple Who Asked About Bipolar Disorder

I occasionally submit posts to The Mighty, a webpage for people with disabilities. They have a section for mental illness.This is my latest submission about a DBSA meeting I went to last night.

You wanted to know information about your son’s bipolar disorder. At first you asked specific questions about the illness and I did my best to answer them. You told me about your son and I was impressed with his accomplishments and sorry to hear where he was at right now.

One of your questions stuck with me. Is there a physical test? Is the diagnosis just based on observation? It is a common question. I wish I had an x-ray or blood test that would show that my diagnosis is real. People can understand a broken arm or diabetes, but not brain disorders.

It was what I didn’t hear that struck me. I have heard parents with children who won’t get treatment, desperate for answers, trying to figure out how to help them get better. Instead, you sounded like you doubted he really had an illness. I could picture you using the “tough love” approach to get him to be more productive.

My mind went back to my own brother. He had a psychotic illness starting in the late 70s. My father didn’t believe in mental illness so he didn’t really get treated. He died young in an act that was either a reckless accident or intentional, I don’t know.

I told you about my brother. I feel guilty that he didn’t have the chances I do.

I pleaded with you to be gentle with your son. The words slipped out of my mouth that suicide is so common. It has been reported up to 20% of people with bipolar disorder complete suicide. I felt like I said too much and second guessed myself when I came home.

Now, that I have had time to think, I am glad I said something. I did not want to make you feel bad or scare you. I have not met your son and I don’t know where he is at mentally. But, you wanted information and that is a valuable piece of information.

My Family History of Mental Illness

I remember my grandmother in her baggy dresses that covered every inch of her body like the shrouds that covered the furniture when the summer folk had left for the season. My cousin Heidi was surprised when I told her that my grandmother — her aunt — had spent many hours of each day lying in bed.

“But she was always so jolly, so friendly.”

“Yes,” I said. “She could be like that. Like so many of us she knew how to fake happiness.” I do not mean that as a slander. I admire how she could pull herself together despite her suffering and be there.

I know my grandmother loved me. When I was young, she used to get in big fights with my mother for the way she mistreated me. The rows were long and loud — I would go to the very back of the yard so that I could not hear them.

My mother had her own problems: there was a deep-seated meanness in her. She disparaged my grandmother when we were alone together, complaining about what she thought as Stella’s laziness. When I was depressed, she was panicked at the thought that would do the same, so she hectored me about getting a job — any job — no matter how inappropriate or soul-killing it was. Once, when she was in the hospital with roof-busting high blood pressure, I told the doctor about our family secret. A psychiatrist prescribed Prozac. For three months, she was a nice person.

Where are you in “recovering” a life that is meaningful to you?

The biggest loss after I was diagnosed was my poetry. Before my diagnosis, I wrote a lot — I filled a ring binder with it. Two inches of verse, mostly free. Then I stopped because I believed that going to readings and writing it made my condition worse. And I believed that I lost the ability to write it. I did not stop, but my output was meager and sparse. One poem a year. Some years I wrote nothing. But a part of me yearned for the truth and beauty of a fine image. So last spring, I conducted an experiment. Thanks to a psycho-stimulant that gave me a renewed ability to focus, I cautiously began to compose free verse and haiku. To my joy, I did not explode into mania. I was not writing long intense blogs as had been the signature of my mania and I did not lapse into consequent depressions. So I have begun thinking: If I can handle poetry what about spirituality? Could I attend a church without turning into a prophet? Could I handle being a member of a congregation and not its priest? So I have been contemplating where to go, what denomination suits my temperament. That is the next signpost.

The Benefits of Bipolar Disorder

When I am manic, I get things done. That is as long as I am not running to the top of the inside stairs and down again seeking something that I cannot remember. Then it is The Great Eater of Time. My depression helps me to see what projects I have taken up that are pointless wastes like the schemes of making a million quickly by stuffing envelopes at home. I can detect what is rigged: I will not spend hours trying to win games that cannot be won or spend money on hobbies that I will never get around to finishing. I have ships in a bottle that I have not pulled the rigging up. I bought these in hypomania.

Depression has a wisdom about it, bitter at times, with a predictive power and insight into the motives of some men and women. I do not trust certain people when I am in depression: This often proves a smart thing.

Then there is the stillness that comes, a beautiful blue film that falls gently over my consciousness calling for silence and appreciation of the moment. If I shut down the voices that hector me for a moment, I find the peace that the racing thoughts of mania do not permit. I may feel fatigued, but I am not agitated as I am in a mixed state. Depression is a better place in the mind than mania or the vicious mixed state.

Reminded of Algernon

Not sure what triggers so proceed with caution

I have 3 brothers and 2 sisters. I used to have 4 brothers. Pat passed away over 30 years ago. For a long time I didn’t speak about him. Everything upset me too much. I speak some now. But, it is I sad story and I don’t want to discourage people. Different times, different people.

Pat had a breakdown at 20 when he was at college. He came home a different person, first he would just stare. Then he was obviously mentally ill. He claimed he had been brainwashed by a cult,.he was also the soccer player Pele’ and other people. He was unpredictable and scared me. He would try to act ” normal” mimicking others, which was even worse. My father felt Pat could just stop it if he wanted and would yell and even hit him.

my father didn’t believe in mental health treatment and the only help my brother got was when he was picked up on 72 hour holds. They would give him typical antipsychotics, this was the late 70s, and send him home. He would be psychotic and sedated which just made his differences more apparent.

then, in 1985 he was picked up in a different county. They tried a different medication. lithium. Everyone told me he was back like his old self again. It was as close to a miracle as I could imagine. But, when I went to visit he wasn’t well. He was looking at me suspiciously. He was talking about the bible excessively and was hard to understand. My mother said they were having trouble finding the right dosage.of medication.

he took off that night. I never saw him again. He went to Yosemite. He fell at a large waterfall and died. Suicide or risky behavior? I am not sure.

I have all kinds of mixed up feelings. Mainly guilt. That I didn’t try to understand more and be closer and not so afraid, that I didn’t do more to get him some kind of help, that I am fine and he wasn’t.

and just sad that he was fine for a little while and then started to go back into the psychosis he had been trapped in for years.

(About how the title: my children were talking about ” Flowers for Algernon”. I know the story is about intellectual disability, but the idea of improving and then going back to the old state hit me as similar and sparked the memories)

 

A Letter to My Illness

You moved in when I was very young, shoved me into your corner, made me cry and when I cried you caused the kids to laugh at me, taunt me saying “Don’t cry Joel.” Sister Annette told me to buck up, to learn to be a man and hold the tears back. Damn you and damn her. I couldn’t say it at the time. Two years of living under the threat of her ruler, but the taunts were worse, hurt worse. The more they called me names, you and my parents reasoned, the stronger I would become but this practice was flawed. I played alone or with other losers. My mother criticized my choice of friends, calling them slow, hinting that they were retarded. Even among them I lived in a shell and the kids continued to wear at my head, trying to produce the streams of salt water they loved so much to see. I don’t know what brought you to make a home in my head. I don’t know why you made me sensitive to the twist in their voices. Was it the arrival of my two cousins who stayed for a year? If it was, you stayed beyond a year, brought me suffering. I looked at Jesus and wondered what was worse: crucifixion or this hell I was going through? If I was on the cross with Him, it was an absurdity.

Ends of a Mood Swing

My mania feels like a fishing line pulled taut to the breaking point.

My depression feels like I am that same fishing line let to fall in a curled mess and tossed to the bottom of the sea.

My mania feels like omnipotence — the power of God — channeled through my neck, my spine, my limbs, and my eyes.

My depression feels like my failure to be of any effect, like I have botched things up, crippled animals, alienated friends, brought evil into the world.

My mania feels like I can do great things, that I have a destiny that will change the world — bring peace, soften stone hearts, make people live in harmony.

My depression feels like a hole that sucks in everything good, that is no place to hide from despair.

My mania gives me energy to glide up the last spine leading to Everest’s summit and dive without a bathyscaphe to the bottom of the Challenger Deep.

My depression makes me stay in my house dreaming dark dreams.

My mania makes me love all humankind — especially women — and spark with anger if the purity of that love is questioned.

My depression makes me the lover of my pillow, my sheets, and my blanket, a friend of the curtained darkness, the noises of the day, and the deep emptiness of the night.