An external change: The War Inside

In 1992, I went to former Yugoslavia to help the peace movements there instead of getting another soul-ripping job as an administrator. Twenty five years later, I still wonder if I did the right thing, if I did any good in the world. I wrote about my experiences in the way that I like to write, walking around what I saw and thinking about what it meant. People wanted me to go back, but I raised money for the peace groups so they could have offices, supplies, and the like. It did not seem right for me to finance any more “vacations”.

In the end, I never went back. I fell into a depression that lasted for nine months before I had the faith and the courage to admit that I had a problem. I turned to Lynn and said “I’m sick.” Sickness had not begun that day or that year. It had been with me a long time. It was like the guns booming and the machine gun fire I heard in Croatia. Loud. But I could ignore it. Background noise. My illness was background noise that I could shove aside. But the booms never stopped the war inside kept raging, and there was debris all over the streets of my inner city. I wasn’t going back to Osijek. I had a new form for my illness, a new, sick metaphor.

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

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.

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.

How My Condition is Changing Over Time

I haven’t had the problem with side effects that others have had. Except for the weight. The fucking weight. I went to my endocrinologist the other day and learned that my A1C levels had gone down five points. Of course, I over-ate to celebrate, but the maddening thing is that my weight isn’t changing: I continue to hover between 250 and 260 pounds! We have no explanation for this, my doctor and I, but it is noted.

Damn the weight! The blame falls almost entirely on my Risperidone, an antypical anti-psychotic. My mood stabilizers are kind on this point, but my Risperdal has transformed me from a reed shaking in the wind to a baobab — a huge club of a tree that eats up city blocks in Africa. The other night I took a nearly nude selfie. My stomach stood out like a bump on an oak tree. I looked like I was heavily pregnant, ready to drop a cat or a foal. The hair on my belly spread out from my navel like grass on a tiny planet. But I have been rewarded with calmer moods, gentleness, and peace of mind. I’ll find a way to reduce the weight.

The Day of My Diagnosis

This is the text of a speech I delivered on September 22, 2016

Twenty two years ago, when I was almost thirty six, I woke up one morning and said “Lynn, I’m sick.”. I had been in bed for weeks. I’d lost my appetite. We made an appointment with the psychiatric department at Kaiser Redwood City and by the end of the following week I was on Prozac.

Prozac was amazing stuff: I was cured the next day. My psychiatrist was surprised but because i had never told him about my other symptoms — the irritability, the paranoia, the rapid speech, that time in college when i had gone up to San Francisco with my girlfriend and come back with my girlfriend and they were two different people — he let things be. In time, our insurance changed, so I came under the care of a nice gentleman in Menlo Park who also had no clue about my other symptoms so he made no changes. Then we moved down here and I found a new psychiatrist who also made no changes because I never told her about my other symptoms either.

Then one day the Prozac stopped working, so she changed me over to Effexor. I found myself in a burning darkness. Two things happened. First, an editor was taking forever to get back to me on a story. Second, I overheard Lynn saying something about me to her sister. My irritability merged with my despair. I went for a walk in Whiting Ranch, called a friend — who found my anxiety funny for some reason. So I texted my last will and testament to Lynn, making special note to leave some possessions of my father to my nephew and asking her to be sure to be sure to get my poetry published after my death. Then I sat down on a sycamore log, studied my veins, and prepared to bread my glasses.

My cell phone rang. It was my psychiatrist. “Are you all right?”.

“No,” I whimpered. She told me to go down to South Coast Medical Center. Lynn picked me up and drove me to Laguna Beach

After spending several hours in the emergency room getting my chest x-rayed because I was wheezing, they took me down to the behavioral unit where I left Lynn at the door. They took away my shoelaces and my glasses, then showed me my room.

I came out after an hour. “I am diabetic,” I yelled. “I need my blood sugar medicine!” I can only imagine what was going through their minds — “this guy was brought here because he was preparing to commit suicide and now he wants the medicine her takes to keep himself alive” — but I am sure they took careful notes.

The next day when i went to group i was the happiest person there. Everyone was miserable except for me who was laughing at the fact that he had attempted suicide and lived to tell about it.

After group, I waited around until I was called into a consulting room. A psychiatrist joined me there. He took a few minutes to read over the notes the ER doctor and the nurses had made. Then he looked at me and asked in a very gentle voice “Had anyone ever told you that you were bipolar?”

And that is when my recovery began.

What Does it Take to Make a Diagnosis?

There are a couple of people who sometimes respond to my threads who don’t like it when I say we shouldn’t be calling people mentally ill just because we don’t like them or act in ways that we don’t like. I think it is time for me to outline what is required to make a diagnosis:

  • You have to be trained as a psychiatrist or a clinical psychologist. (Most “experts” or the “peanut crunching crowd” are not.)
  • You have to have actually examined the person. This goes beyond watching them on television or reading about them in magazines or newspapers.
  • You have to use proper diagnostic criteria.
  • You must be neutral. Most of the pseudo-diagnoses that I have seen fail magnificently on this score. In my experience, progressives are the worst, but this does not exonerate others including conservatives.
  • You must have the patient’s welfare in mind, not an opportunity to insult.
  • You must avoid stigmatizing people with mental illness who are not anything like the person you are diagnosing. E.g. By saying that terrorists are mentally ill, you are implying that people who are mentally ill are like terrorists. (Research shows that people with mental illness are less likely to be violent than the normal population.