The Obsessive-Compulsive Disorder: Struggle to Stop

John’s arms are so dry his skin has turned white and powdery. His scrubbed blond hair, devoid of oil, stands straight up like dead grass. His face is red and chapped and clean as a whistle. But still John must wash.

For fear of getting dirty or contaminated, John will not touch most things in his house. He sits in only a couple of chairs carefully covered with sheets and towels and uses tissues to open doors and turn on lights. At night he showers for hours at a time. He says he goes through 15 bars of soap and six boxes of tissues a week.

John, 60, has been diagnosed as having obsessive-compulsive disorder, a relatively rare psychological illness in which a person has an obsessive, recurring thought that compels some action.

Until recently, the disease was considered quite rare, but recent statistics suggest that about 1% of the population may be afflicted with obsessive-compulsive disorder, about as many people as are afflicted with schizophrenia.

“The key feature of the disease is the internal struggle,” said Tom Insel, a psychiatrist at the National Institute of Mental Health who has extensively studied obsessive-compulsive disorder. “Sufferers describe their illness as a battle between the impulse to do something and the struggle to stop it.”

Feeling of Contamination

John’s obsession is that he is dirty, and that many of the things in his world are contaminated in some vague way. The obsession produces a compulsion to wash, and to avoid touching “contaminated” things like doorknobs, light switches, or anything that has come into contact with the floor.

John, a West Los Angeles contractor, led a normal life until four years ago. Then he began noticing changes. He had always enjoyed going to the race track, spending an occasional day watching the horses and betting a few dollars. But he began to feel dirty at the track and before leaving, he felt compelled to scrub himself, to wash his wallet and to carefully wipe the steering wheel of his car. He knew it made no sense; he just had to do it.

In a couple of months, his cleanliness obsession had pervaded every aspect of his life. He quit going out, and lost interest in just about everything--except washing.

By late in the summer of 1985, John and his wife, Evelyn, were in a panic. “He was taking hours-long showers, keeping me up all night. He was also swearing and yelling at himself all the time. He was entirely out of control,” she recalled.

“I had reached the end of my rope,” Evelyn said. “I even called a lawyer about getting a divorce, but he said we would have to sell the house and I didn’t want to do that.”

Instead, she called a local crisis center, which referred John and Evelyn to UCLA’s Neuropsychiatric Institute, where John began seeing Dr. Lewis Baxter, a psychiatrist with considerable experience treating obsessive compulsives.

Baxter says John’s symptoms are typical of contamination obsession, one of a number of manifestations of obsessive-compulsive disorder. Other forms of the disease include compulsive checking or counting, recurring and uncontrollable intrusive thoughts, and primary obsessional slowness.

Compelled to Recheck

A compulsive checker is someone who becomes concerned about something and then must check it over and over. For example, the checker might wonder if he left the stove on, and then be compelled to check it not once but dozens of times.

Someone suffering from intrusive thoughts will think about something violent or catastrophic, and then be unable to rid himself of those thoughts, sometimes for days.

An obsessive compulsive with primary obsessional slowness ritualizes normal behaviors to such an extent that brushing his teeth or hair can take up to six hours a day. Baxter describes, for example, one patient who was near starvation because his eating rituals were so complicated he took all day to eat and still was getting insufficient calories.

Baxter says that obsessive compulsives know their behavior is highly abnormal, but are unable to control it. “It is among the most devastating diseases,” Baxter said. “These people are acutely aware they are ill, and they are consumed with guilt.”

Until recently, the disease has not received much attention in the United States. “It’s a kind of disorder that hasn’t really captured the American imagination,” said psychiatrist Tom Insel of the National Institute of Mental Health. “It just doesn’t have the sexiness of anorexia nervosa or panic disorder, both of which are far less common.”

Some experts in treating obsessive compulsive disorder have reported excellent results using behavior modification to treat patients. The therapy has two components--exposure and response prevention.

“Treatment involves the gradual confrontation of the patients with objects or situations they are afraid of,” said Dr. Edna Foa, a professor of psychiatry at Pennsylvania Medical College who treats patients at the college’s Center for the Clinical Study of Anxiety. “Then we prevent patients from responding as they would ordinarily.”

By way of example, Foa told the story of a woman with contamination obsession. The woman thought her mother and anything connected to her mother were contaminated. When she sought treatment from Foa, the woman hadn’t seen her mother in six years. She wouldn’t handle money because her mother or someone near her might have touched the money.

She wouldn’t read or touch the local paper, because a neighbor of her mother’s worked for it. She required her husband to shower in the basement and wash his clothes before coming upstairs, because he worked with a man from her mother’s neighborhood.

During two weeks of treatment, the woman was at first instructed to handle the newspaper. Next she handled money. Then her husband’s clothes. During the period of exposure, she wasn’t allowed to wash and decontaminate herself.

Finally, the woman’s mother was brought to the clinic, and the women embraced and sat near each other. For another week, the mother lived in her daughter’s home. By the end of treatment, the patient was free of symptoms.

Foa says that such treatment has been extremely effective in treating many of the approximately 200 patients she has seen since 1972 at the Center for Clinical Study of Anxiety, although she acknowledges the treatment isn’t always successful.

Baxter concurs. “For certain obsessive compulsives, behavior therapy is highly effective, but there are many people who don’t respond to that.”

For such patients, there was little hope until recently. Now, however, psychiatrists treating the disease are guardedly optimistic about several seeming breakthroughs in understanding and in treating the disease.

Through the use of Positron Emission Tomography scans, which give a computerized picture of brain energy activity, Baxter and others at UCLA have begun studying the brains of obsessive compulsives. Although only a small number of subjects has yet been tested, the results seem to point to clear differences between the brains of obsessive compulsives and the brains of others.

Of particular interest to researchers are two things. First, they have found that many parts of the brains of obsessive compulsives show a higher than normal metabolic rate. But even more important, they suspect, is that a section of the central brain called the caudate may play an important role in obsessive-compulsive disorder.

Brain researchers have long speculated that the caudate serves as a sort of central switching area of the brain, that it serves as a sender and receiver of messages from one part of the brain to another.

In the brains of obsessive compulsives the caudate is unable to keep pace with another abnormally active part of the brain, the orbital gyrus. Therefore, researchers speculate, the caudate may not be able to modulate obsessive thoughts.

Others in the field are watching Baxter’s research with interest. “His PET studies are compelling because they are new and unexpected. They are also sturdy. The results aren’t equivocal as is so often the case,” said Daniel X. Freedman, Judson Braun professor of psychiatry and pharmacology at UCLA and editor of the Archives of General Psychiatry.

Also changing is the treatment of obsessive-compulsive disorder. For several years, researchers have known that the anti-depressant clomipramine has had some positive effect on obsessive compulsives. But the drug is unavailable in the United States.

Recently, however, reports of the drug’s effectiveness have prompted its manufacturer, Ciba-Geigy, to conduct U.S. trials of the drug as a preliminary step to possibly seeking FDA licensing of the drug.

Conducting Trials

Gloria Martini, a spokeswoman for Ciba-Geigy, said the controlled trials will be conducted at 21 study centers throughout the country, including UCLA. “We started the trials this summer, and they will run for a minimum of two years,” Martini said. At that time, depending on results, the company will decide whether to make application to the FDA.

Dr. David Fogelson, one of the psychiatrists heading the UCLA test, said the trial began Nov. 15 and that he is still seeking obsessive-compulsive patients to participate.

Baxter and other UCLA researchers have also seen excellent preliminary results treating obsessive compulsives with another anti-depressant, Desyrel, which is known to stimulate seratonin receptors in the brain.

No controlled studies have yet been completed, but researchers at UCLA and two other centers are also conducting a study in which some obsessive compulsives are taking Desyrel while others are taking placebos or another anti-depressant. Of 15 patients treated with the drug outside the study, all who could take the drug without serious side effects have shown significant improvement.

Looking at the initial Desyrel results Freedman too is hopeful. “They’re encouraging. In the continuing search for the specific treatment of the specific disorder, Desyrel looks like an important step along the way, although we don’t yet have the prize in hand.”

John is among those for whom Baxter prescribed Desyrel. Within two months of starting the drug, he and his wife saw some significant improvement and are, for the first time, hopeful. Now, Baxter has added other drugs and some behavior modification to John’s regimen of psychotherapy in an attempt to get even more improvement.

“He now goes out a few nights a week. On Wednesday nights we go dancing. This would have been unheard of before,” Evelyn said.

Although John still washes far more than is normal and is unable to touch many things in his house, Evelyn says he has cut back significantly the amount of time he spends washing. “I was done,” she said. “I couldn’t see that he’d get any better, and I just couldn’t have gone on.”